Basic Information
| Provider Information | |||||||||
| NPI: | 1306244611 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIDLER | ||||||||
| FirstName: | KIMBERLY | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9222 W RYAN CT | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672052164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166506945 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2101 N WALDRON ST | ||||||||
| Address2: | |||||||||
| City: | HUTCHINSON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675021131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206692500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2014 | ||||||||
| LastUpdateDate: | 06/24/2015 | ||||||||
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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 | 146L00000X | 030263 | KS | N | Emergency Medical Service Providers | Emergency Medical Technician, Paramedic | 363L00000X | 53-76358-121 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | F0714783 | 01 | KS | AANP-AMERICAN ACADEMY OF NURSE PRACTITIONERS | OTHER | PENDING | 05 | KS | MEDICAID |