Basic Information
| Provider Information | |||||||||
| NPI: | 1306014949 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLEISCHHAUER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CST, CFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5545 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479035545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654488000 | ||||||||
| FaxNumber: | 7654488335 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 FERRY ST | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479043055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654488000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2008 | ||||||||
| LastUpdateDate: | 03/13/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | F01392 | IN | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant | 246ZS0410X | F01392 | IN | N |
ID Information
| ID | Type | State | Issuer | Description | 000000553136 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER |