Provider Demographics
NPI:1336641646
Name:POOLE, KIMBERLY L (FNP-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:POOLE
Suffix:
Gender:
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3403 E RAYMOND STREET
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-4744
Mailing Address - Country:US
Mailing Address - Phone:317-957-2000
Mailing Address - Fax:
Practice Address - Street 1:6020 CRAWFORDSVILLE RD STE 102
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-3710
Practice Address - Country:US
Practice Address - Phone:317-957-2070
Practice Address - Fax:317-957-2560
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28191368A163WP0200X
IN71009540A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300032899Medicaid