Provider Demographics
NPI:1205242369
Name:JIVIDEN, KIMBERLY A (CNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:JIVIDEN
Suffix:
Gender:F
Credentials:CNP
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 609
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:WV
Mailing Address - Zip Code:26143-0609
Mailing Address - Country:US
Mailing Address - Phone:304-275-3301
Mailing Address - Fax:304-275-4798
Practice Address - Street 1:483 COURT ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:WV
Practice Address - Zip Code:26143-1109
Practice Address - Country:US
Practice Address - Phone:304-275-3301
Practice Address - Fax:304-275-4798
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV58709363LF0000X
OHRN298807163W00000X
OHCOA.16207-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP01439933OtherRAILROAD MEDICARE - MHCPI
WV1205242369Medicaid
WV3810029263Medicaid
OH0107154Medicaid