Basic Information
| Provider Information | |||||||||
| NPI: | 1184809691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOLTE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 188 HOSPITAL DR | ||||||||
| Address2: | STE 402 | ||||||||
| City: | FAIRHOPE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365322043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2519901740 | ||||||||
| FaxNumber: | 2519901747 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 S INGLESIDE ST STE 6 | ||||||||
| Address2: | |||||||||
| City: | FAIRHOPE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365321804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2519901740 | ||||||||
| FaxNumber: | 2519901831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2008 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1-072405 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 145466 | 05 | AL | MEDICAID | 51131838 | 01 | AL | BCBS | OTHER |