Provider Demographics
NPI:1699037119
Name:MCNALLY, KIMBERLY NICOLE (DNP, CNM, FNP-C)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:MCNALLY
Suffix:
Gender:F
Credentials:DNP, CNM, FNP-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:NICOLE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:1033 127TH LN NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-4021
Mailing Address - Country:US
Mailing Address - Phone:804-381-9709
Mailing Address - Fax:
Practice Address - Street 1:1515 COUNTY ROAD B W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-6005
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170091363LF0000X, 367A00000X
MN619367A00000X
MN12475363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500739555Medicaid