Provider Demographics
NPI:1194719922
Name:KIMBLEY, TERRI (ANP)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:KIMBLEY
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:
Other - Last Name:MCCART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2900 16TH ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-3510
Mailing Address - Country:US
Mailing Address - Phone:812-275-5352
Mailing Address - Fax:812-275-1374
Practice Address - Street 1:2900 16TH ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-3510
Practice Address - Country:US
Practice Address - Phone:812-275-5352
Practice Address - Fax:812-275-1374
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000989B363L00000X
IN71000989363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000307493OtherANTHEM PROVIDER #
IN200224680AMedicaid
IN000000307493OtherANTHEM PROVIDER #