Provider Demographics
NPI:1083415053
Name:BANEY, KIMBERLY SUE (FNP-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:BANEY
Suffix:
Gender:
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3440 S TINKEY RD
Mailing Address - Street 2:
Mailing Address - City:MENTONE
Mailing Address - State:IN
Mailing Address - Zip Code:46539-9288
Mailing Address - Country:US
Mailing Address - Phone:574-253-5809
Mailing Address - Fax:
Practice Address - Street 1:3440 S TINKEY RD
Practice Address - Street 2:
Practice Address - City:MENTONE
Practice Address - State:IN
Practice Address - Zip Code:46539-9288
Practice Address - Country:US
Practice Address - Phone:574-253-5809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28173352A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner