Provider Demographics
NPI:1255804613
Name:ANDERSON, KIMBERLY MARIE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:SOMERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8558 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7032
Mailing Address - Country:US
Mailing Address - Phone:219-392-7084
Mailing Address - Fax:219-703-6854
Practice Address - Street 1:3800 SAINT MARY RD STE 102
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-3986
Practice Address - Country:US
Practice Address - Phone:219-286-3707
Practice Address - Fax:219-286-3708
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.019967363LF0000X
IN71008722A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300023556Medicaid