Provider Demographics
NPI:1952923310
Name:BRASSEUR, KIMBERLY JO (RN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JO
Last Name:BRASSEUR
Suffix:
Gender:F
Credentials:RN, PMHNP-BC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JO
Other - Last Name:RANKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, PMHNP-BC
Mailing Address - Street 1:4762 LEGARE LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43230-6388
Mailing Address - Country:US
Mailing Address - Phone:304-593-0781
Mailing Address - Fax:
Practice Address - Street 1:3099 SULLIVANT AVE STE H
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-1800
Practice Address - Country:US
Practice Address - Phone:614-371-2303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0028798363LP0808X
OHRN.471177163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0442071Medicaid