Basic Information
| Provider Information | |||||||||
| NPI: | 1053818450 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENSON | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | CARLY NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HURT | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | CARLY NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 908 SCARBRO RD | ||||||||
| Address2: | |||||||||
| City: | SCARBRO | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259178837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044692905 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 908 SCARBRO RD | ||||||||
| Address2: | |||||||||
| City: | SCARBRO | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259178837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044692905 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2018 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 467275 | OH | N | Nursing Service Providers | Registered Nurse | 163W00000X | 97400 | WV | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 108428 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 0024180856 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.