Basic Information
| Provider Information | |||||||||
| NPI: | 1720064173 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 MAIN ST S | ||||||||
| Address2: | |||||||||
| City: | MC KEE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404477089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062877104 | ||||||||
| FaxNumber: | 6062874409 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 ESTILL ST | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404031742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599851415 | ||||||||
| FaxNumber: | 8599866752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 06/05/2014 | ||||||||
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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 | 363L00000X | 3743P | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 78009909 | 05 | KY | MEDICAID |