Provider Demographics
NPI:1831255744
Name:ANDERSON, KIMBERLEY JO (CNM)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:JO
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 S PROMENADE BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8609
Mailing Address - Country:US
Mailing Address - Phone:479-372-4560
Mailing Address - Fax:877-461-6743
Practice Address - Street 1:5302 W VILLAGE PKWY STE 3
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8139
Practice Address - Country:US
Practice Address - Phone:479-372-4560
Practice Address - Fax:877-461-6743
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARM002134176B00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR222290799Medicaid
MOG84D053Medicare ID - Type Unspecified