Provider Demographics
NPI:1316979230
Name:MILLS, KIMBERLY J (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:MILLS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8244 E US HIGHWAY 36
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9575
Mailing Address - Country:US
Mailing Address - Phone:317-272-7500
Mailing Address - Fax:317-272-7515
Practice Address - Street 1:8244 E US HIGHWAY 36
Practice Address - Street 2:SUITE 1100
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-9575
Practice Address - Country:US
Practice Address - Phone:317-272-7500
Practice Address - Fax:317-272-7515
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000882B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200545530Medicaid
INS76554Medicare UPIN
IN143110SMedicare ID - Type Unspecified