Provider Demographics
NPI:1740759042
Name:MILLS, KIMBERLY DIANE (APRN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
Last Name:MILLS
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 1:4411 WASHINGTON AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0805
Mailing Address - Country:US
Mailing Address - Phone:812-213-0304
Mailing Address - Fax:
Practice Address - Street 1:4411 WASHINGTON AVE STE 105
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0805
Practice Address - Country:US
Practice Address - Phone:812-213-0304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71014784A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100579830Medicaid