Provider Demographics
NPI:1720044142
Name:BODEMANN, KIMBERLY R (APRN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:R
Last Name:BODEMANN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21850
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71903-1850
Mailing Address - Country:US
Mailing Address - Phone:501-623-2781
Mailing Address - Fax:501-623-1774
Practice Address - Street 1:1662 HIGDON FERRY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6912
Practice Address - Country:US
Practice Address - Phone:501-623-2781
Practice Address - Fax:501-623-1774
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARS01064CNS364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR183336758Medicaid
ARP00196832Medicare PIN
AR5U1627470Medicare PIN