Basic Information
| Provider Information | |||||||||
| NPI: | 1720090947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREEMAN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | MELLENCAMP | ||||||||
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| Credential: | C.N.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2325 18TH ST | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472015388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123750272 | ||||||||
| FaxNumber: | 8123751093 | ||||||||
| Practice Location | |||||||||
| Address1: | 2325 18TH ST | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472015388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123750272 | ||||||||
| FaxNumber: | 8123751093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 05/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | 28116944A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
No ID Information.