Provider Demographics
NPI:1699037119
Name:MCNALLY, KIMBERLY NICOLE (DNP, CNM, IBCLC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:MCNALLY
Suffix:
Gender:F
Credentials:DNP, CNM, IBCLC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:NICOLE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:1814 BRIARCLIFF RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-2306
Mailing Address - Country:US
Mailing Address - Phone:804-381-9709
Mailing Address - Fax:
Practice Address - Street 1:1909 HUGUENOT RD STE 201
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4314
Practice Address - Country:US
Practice Address - Phone:804-381-9709
Practice Address - Fax:804-533-5997
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170091367A00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500739555Medicaid