Provider Demographics
NPI:1649327743
Name:NEACE, KIMBERLY S (RN MSN CNP)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:S
Last Name:NEACE
Suffix:
Gender:F
Credentials:RN MSN CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11117 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47012-5154
Mailing Address - Country:US
Mailing Address - Phone:937-603-4507
Mailing Address - Fax:
Practice Address - Street 1:11117 BEECH ST
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:IN
Practice Address - Zip Code:47012-5154
Practice Address - Country:US
Practice Address - Phone:937-603-4507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA04947363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2197359Medicaid
OH9386101OtherMEDICARE