Provider Demographics
NPI:1780825570
Name:BERTHOLD, KIMBERLY A (RN, BC, FNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:BERTHOLD
Suffix:
Gender:F
Credentials:RN, BC, FNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:A
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BC, FNP
Mailing Address - Street 1:4330 WORNALL RD
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-5939
Mailing Address - Country:US
Mailing Address - Phone:816-931-1883
Mailing Address - Fax:816-756-3645
Practice Address - Street 1:20 NE SAINT LUKES BLVD
Practice Address - Street 2:SUITE 240
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-6001
Practice Address - Country:US
Practice Address - Phone:816-931-1883
Practice Address - Fax:816-756-3645
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008001025363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200258340DMedicaid
KS200258340EMedicaid
MOP00836071OtherRAILROAD MEDICARE
KSP00842733OtherRAILROAD MEDICARE
MO1780825570Medicaid
KS200258340DMedicaid
MOMA2492013Medicare PIN
KSKA2004046Medicare PIN
KSKA1724046Medicare PIN