Provider Demographics
NPI:1801468921
Name:SHAY, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SHAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4788 BRAYSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:IN
Mailing Address - Zip Code:47460-5040
Mailing Address - Country:US
Mailing Address - Phone:812-585-1629
Mailing Address - Fax:
Practice Address - Street 1:920 W HWY 46
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IN
Practice Address - Zip Code:47460
Practice Address - Country:US
Practice Address - Phone:812-585-1629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28240430A364SL0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28240430AOtherRN