Provider Demographics
NPI:1881626331
Name:BRUYERE, KIMBERLY K (ANP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:K
Last Name:BRUYERE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 RIFE MEDICAL LN
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1452
Mailing Address - Country:US
Mailing Address - Phone:479-338-3888
Mailing Address - Fax:479-338-4453
Practice Address - Street 1:2708 RIFE MEDICAL LN
Practice Address - Street 2:SUITE 210
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1452
Practice Address - Country:US
Practice Address - Phone:479-338-3888
Practice Address - Fax:479-338-4453
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA003069363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200014600AMedicaid
KS130543Medicare ID - Type Unspecified
MO000081295Medicare ID - Type Unspecified
KS9004186Medicare ID - Type UnspecifiedKANSAS CITY
KS100338030BMedicaid
OK400522296Medicare ID - Type Unspecified
MO424876217Medicaid
AR5A771Medicare PIN
S77389Medicare UPIN
MO163956OtherBCBS
MO500026787Medicare ID - Type UnspecifiedRAILROAD