Basic Information
| Provider Information | |||||||||
| NPI: | 1255840401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGILLICUDDY | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PMH-NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEYSE | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 30 W RAMPART ST SUITE 200 | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461768846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174212012 | ||||||||
| FaxNumber: | 3173981851 | ||||||||
| Practice Location | |||||||||
| Address1: | 2451 INTELLIPLEX DR SUITE 260 | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461768580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173980121 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71007536A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | 71007536A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 163W00000X | 28199185A | IN | N | Nursing Service Providers | Registered Nurse |
No ID Information.