Provider Demographics
NPI:1730296591
Name:HERTLEIN, KIMBERLY L (ANP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:HERTLEIN
Suffix:
Gender:F
Credentials:ANP
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 3528
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72913-3528
Mailing Address - Country:US
Mailing Address - Phone:479-274-2000
Mailing Address - Fax:479-274-2194
Practice Address - Street 1:303 S 5TH ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:AR
Practice Address - Zip Code:72855-4501
Practice Address - Country:US
Practice Address - Phone:479-963-2132
Practice Address - Fax:479-963-2046
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01805363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
080017768OtherRR MEDICARE
AR157386758Medicaid
Q30127Medicare UPIN
080017768OtherRR MEDICARE