Provider Demographics
NPI:1295810786
Name:MCKENNA, KIMBERLY ROSE (ARNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ROSE
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WINSTON WAY STE 5
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-4991
Mailing Address - Country:US
Mailing Address - Phone:270-789-0034
Mailing Address - Fax:270-789-0097
Practice Address - Street 1:106 WINSTON WAY
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-4953
Practice Address - Country:US
Practice Address - Phone:270-789-0034
Practice Address - Fax:270-789-0097
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261QR1300X
KY4091P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78012481Medicaid
KYQ01244Medicare UPIN
KY78012481Medicaid