Basic Information
| Provider Information | |||||||||
| NPI: | 1730296591 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERTLEIN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3528 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729133528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792742000 | ||||||||
| FaxNumber: | 4792742194 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | PARIS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728554501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799632132 | ||||||||
| FaxNumber: | 4799632046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 08/28/2015 | ||||||||
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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 | 363L00000X | A01805 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 080017768 | 01 | RR MEDICARE | OTHER | 157386758 | 05 | AR | MEDICAID |