Provider Demographics
NPI:1386364164
Name:LANGE, KIMBERLY KAY (FNP-BC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAY
Last Name:LANGE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13342 WHITE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-8401
Mailing Address - Country:US
Mailing Address - Phone:810-278-6646
Mailing Address - Fax:
Practice Address - Street 1:13342 WHITE LAKE RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-8401
Practice Address - Country:US
Practice Address - Phone:810-278-6646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704224018363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily