Provider Demographics
NPI:1255605895
Name:LORENTZ, KIMBERLY R (ANP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:R
Last Name:LORENTZ
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:RENEE
Other - Last Name:WINGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1241 W STADIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-6023
Mailing Address - Country:US
Mailing Address - Phone:573-556-1706
Mailing Address - Fax:573-556-1718
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109
Practice Address - Country:US
Practice Address - Phone:573-556-1706
Practice Address - Fax:573-556-1718
Is Sole Proprietor?:No
Enumeration Date:2012-02-29
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012008569363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO147034OtherSTATE RN LICENSE
MO2012008569OtherADULT NURSE PRACTITIONER LICENSE