Basic Information
Provider Information | |||||||||
NPI: | 1407160013 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KERSHNER | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BUTRICK | ||||||||
OtherFirstName: | KIMBERLY | ||||||||
OtherMiddleName: | S | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2580 | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 658012580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4178294620 | ||||||||
FaxNumber: | 4178294316 | ||||||||
Practice Location | |||||||||
Address1: | 1235 E CHEROKEE ST | ||||||||
Address2: | SUITE 2B | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 658042203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4178203064 | ||||||||
FaxNumber: | 4178208862 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/06/2010 | ||||||||
LastUpdateDate: | 10/14/2010 | ||||||||
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 | 146907 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 1407160013 | 05 | MO |   | MEDICAID | 431560263 | 01 |   | TRICARE WEST | OTHER | 183615758 | 05 | AR |   | MEDICAID |