Provider Demographics
NPI:1720064173
Name:EDWARDS, KIMBERLY DIANE (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
Last Name:EDWARDS
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 1:1010 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:MC KEE
Mailing Address - State:KY
Mailing Address - Zip Code:40447-7089
Mailing Address - Country:US
Mailing Address - Phone:606-287-7104
Mailing Address - Fax:606-287-4409
Practice Address - Street 1:305 ESTILL ST
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1742
Practice Address - Country:US
Practice Address - Phone:859-985-1415
Practice Address - Fax:859-986-6752
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3743P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78009909Medicaid
KY78009909Medicaid
KY0737408Medicare PIN