Provider Demographics
NPI:1154406064
Name:EPPS, KIMBRA ANN (FNP)
Entity type:Individual
Prefix:
First Name:KIMBRA
Middle Name:ANN
Last Name:EPPS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2423 NW TROOST ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-1706
Mailing Address - Country:US
Mailing Address - Phone:541-210-8721
Mailing Address - Fax:
Practice Address - Street 1:2460 NW STEWART PARKWAY
Practice Address - Street 2:SUITE 240
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471
Practice Address - Country:US
Practice Address - Phone:541-677-4427
Practice Address - Fax:541-677-6522
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR89000514N1363LF0000X
OR89-000514N1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
R103163OtherMEDICARE PART B
R103163OtherMEDICARE PART B
S73033Medicare UPIN
R103163OtherMEDICARE PART B
R103163Medicare Oscar/Certification
S73033Medicare UPIN
381846Medicare Oscar/Certification
115988Medicare PIN
ORS73033Medicare UPIN
OR168395Medicaid
943096772OtherTAX ID