Provider Demographics
NPI:1821273830
Name:KISEGY, KIMBERLY MICHELE (APRN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELE
Last Name:KISEGY
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3991 DUTCHMANS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4700
Practice Address - Country:US
Practice Address - Phone:502-897-2440
Practice Address - Fax:502-897-2455
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5185P363LF0000X
KY3005185363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000770823OtherANTHEM - NOTC
KY136776OtherSIHO - NOTC
KY50039556OtherPASSPORT - NOTC
KY7100202790Medicaid
KY50039556OtherPASSPORT - NOTC