Provider Demographics
NPI:1396062857
Name:BERGHAUS, KIM (NP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:BERGHAUS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY
Mailing Address - Street 2:STE 129
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4917
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:1578 HIGHWAY 44 E UNIT 2
Practice Address - Street 2:
Practice Address - City:SHEPHERDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40165-7172
Practice Address - Country:US
Practice Address - Phone:502-921-4161
Practice Address - Fax:502-921-4165
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006422363LF0000X
KY6422P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily