Provider Demographics
NPI:1215171251
Name:CECIL-RIDDLE, KIMBERLY (DNP, APRN, FNP-BC)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:CECIL-RIDDLE
Suffix:
Gender:F
Credentials:DNP, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 WALTER GARRETT LANE
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:42262
Mailing Address - Country:US
Mailing Address - Phone:270-640-5821
Mailing Address - Fax:844-270-5587
Practice Address - Street 1:2801 WALTER GARRETT LANE
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:KY
Practice Address - Zip Code:42262
Practice Address - Country:US
Practice Address - Phone:270-640-5821
Practice Address - Fax:844-270-5587
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004526363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ020269Medicaid
KYK202700OtherMEDICARE: INDIVIDUAL
474415234OtherTRICARE
KY7100395690Medicaid
KYK202701OtherMEDICARE GROUP (ST. MICHAEL'S)