Provider Demographics
NPI:1780651505
Name:SMITH, KIMBERLY MOSER (APN)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:MOSER
Last Name:SMITH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 E. MAIN STREET
Mailing Address - Street 2:MELBOURNE MEDICAL CLINIC
Mailing Address - City:MELBOURNE
Mailing Address - State:AR
Mailing Address - Zip Code:72556
Mailing Address - Country:US
Mailing Address - Phone:870-368-4344
Mailing Address - Fax:870-368-3051
Practice Address - Street 1:1526 E MAIN STREE
Practice Address - Street 2:MELBOURNE MEDICAL CLINIC
Practice Address - City:MELBOURNE
Practice Address - State:AR
Practice Address - Zip Code:72556-3736
Practice Address - Country:US
Practice Address - Phone:870-368-4344
Practice Address - Fax:870-368-3051
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01757363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP00130335OtherRAILROAD MEDICARE
AR152621758Medicaid
AR152621758Medicaid
AR5X838Medicare ID - Type Unspecified