Provider Demographics
NPI:1649661372
Name:FERRIS, KIMBERLY R (CPNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:FERRIS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:KIMBELY
Other - Middle Name:R
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:4900 MUELLER BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3079
Mailing Address - Country:US
Mailing Address - Phone:512-324-0000
Mailing Address - Fax:
Practice Address - Street 1:4900 MUELLER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3079
Practice Address - Country:US
Practice Address - Phone:512-324-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128814363LP0200X
CORN 199820363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3535270-01Medicaid