Provider Demographics
NPI:1912928862
Name:KIMBLE, BONNELIA M (APRN)
Entity Type:Individual
Prefix:
First Name:BONNELIA
Middle Name:M
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:6420 DUTCHMANS PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3372
Practice Address - Country:US
Practice Address - Phone:502-891-8300
Practice Address - Fax:502-891-8338
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4268P363L00000X
KY3004268363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00992186OtherRAILROAD MEDICARE - KY
KY000000693047OtherANTHEM - NCVA
KY000000533456OtherANTHEM PIN
KY122023OtherSIHO - NCVA
KY7100147010Medicaid
KY000057080VOtherHUMANA - NCVA
KY122023OtherSIHO - NCVA
KY000000693047OtherANTHEM - NCVA