Provider Demographics
NPI:1013066620
Name:KOVACICH, KIMBERLY A (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:KOVACICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5189 W 600 NORTH
Mailing Address - Street 2:
Mailing Address - City:MCCORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46055-9566
Mailing Address - Country:US
Mailing Address - Phone:317-335-5189
Mailing Address - Fax:317-324-4073
Practice Address - Street 1:5189 W 600 N
Practice Address - Street 2:
Practice Address - City:MCCORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46055-9715
Practice Address - Country:US
Practice Address - Phone:317-335-1588
Practice Address - Fax:317-324-4073
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000468A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN067460Medicare PIN