Provider Demographics
NPI:1851085203
Name:ANDERSON, KIMBERLY GRACE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:GRACE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:GRACE
Other - Last Name:MIRABAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1325 BLUEBIRD LN
Mailing Address - Street 2:
Mailing Address - City:DES ARC
Mailing Address - State:AR
Mailing Address - Zip Code:72040-3496
Mailing Address - Country:US
Mailing Address - Phone:501-388-2150
Mailing Address - Fax:
Practice Address - Street 1:1501 ALDERSGATE RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6611
Practice Address - Country:US
Practice Address - Phone:501-666-7526
Practice Address - Fax:501-660-7876
Is Sole Proprietor?:No
Enumeration Date:2023-06-07
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR123169363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily