Provider Demographics
NPI:1356347199
Name:ANNA, KIMBERLY (APRN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ANNA
Suffix:
Gender:F
Credentials:APRN
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 950244
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0244
Mailing Address - Country:US
Mailing Address - Phone:502-953-4700
Mailing Address - Fax:502-772-8189
Practice Address - Street 1:2215 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1033
Practice Address - Country:US
Practice Address - Phone:502-774-8631
Practice Address - Fax:502-776-8912
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002162363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78009487Medicaid
KY000000199931OtherANTHEM
KY000000199931OtherANTHEM
KY0637719Medicare PIN