Provider Demographics
NPI:1124062161
Name:ANDERSON, KIMBERLY KAY (CNM, APRN)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:KAY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CNM, APRN
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:K
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:906 S 184TH ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-5756
Mailing Address - Country:US
Mailing Address - Phone:402-889-3633
Mailing Address - Fax:531-375-5196
Practice Address - Street 1:11404 W DODGE RD STE 600
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-2593
Practice Address - Country:US
Practice Address - Phone:402-889-3633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA084197363LW0102X
NE110373363LW0102X, 363LP0808X
IAB084197367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
1124062161OtherNPI
NE098962002Medicare PIN