Provider Demographics
NPI:1740835164
Name:BEVERLY, KIMBERLY KAY (PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:KAY
Last Name:BEVERLY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:KAY
Other - Last Name:BURRESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:2904 N RYKERS RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-7648
Mailing Address - Country:US
Mailing Address - Phone:812-701-1591
Mailing Address - Fax:
Practice Address - Street 1:10331 CHAMPION FARMS DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-6129
Practice Address - Country:US
Practice Address - Phone:216-468-5000
Practice Address - Fax:216-456-8128
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4007045363LP0808X
IN28134347A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health