Provider Demographics
NPI:1710436472
Name:MARTIN, KIMBERLY ANNE OGLESBY (APRN-BC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE OGLESBY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 N MARION ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PULASKI
Mailing Address - State:IL
Mailing Address - Zip Code:62548-1069
Mailing Address - Country:US
Mailing Address - Phone:217-971-4101
Mailing Address - Fax:
Practice Address - Street 1:701 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-1069
Practice Address - Country:US
Practice Address - Phone:217-788-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.014904363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041.386754OtherRN LICENSE