Provider Demographics
NPI:1396720751
Name:WERTZ, KIM HICKMAN (NURSE PRACTITIONER F)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:HICKMAN
Last Name:WERTZ
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER F
Other - Prefix:MS
Other - First Name:KIM
Other - Middle Name:HICKMAN
Other - Last Name:AYSCUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTITIONER F
Mailing Address - Street 1:RANDOLPH COLLEGE STUDENT HEALTH CENTER
Mailing Address - Street 2:2500 RIVERMONT AVENUE
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-1526
Mailing Address - Country:US
Mailing Address - Phone:434-947-8130
Mailing Address - Fax:434-947-8106
Practice Address - Street 1:RANDOLPH COLLEGE STUDENT HEALTH CENTER
Practice Address - Street 2:2500 RIVERMONT AVENUE
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24503-1526
Practice Address - Country:US
Practice Address - Phone:434-947-8130
Practice Address - Fax:434-947-8106
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024101663363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAS87458Medicare UPIN