Provider Demographics
NPI:1598863037
Name:NELSON, KIMBERLY JOYCE (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JOYCE
Last Name:NELSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JOYCE
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8841 HIDDEN HILL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-2917
Mailing Address - Country:US
Mailing Address - Phone:817-473-0546
Mailing Address - Fax:
Practice Address - Street 1:5527 FM 636
Practice Address - Street 2:
Practice Address - City:KERENS
Practice Address - State:TX
Practice Address - Zip Code:75144-4001
Practice Address - Country:US
Practice Address - Phone:817-473-0546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX632193363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168683405Medicaid
TX168683401Medicaid
TX168683406Medicaid
TX8N7755OtherBCBS
TX8L24202Medicare PIN
TX168683406Medicaid
TXQ20562Medicare UPIN
TX8L24203Medicare PIN
TX8C1211Medicare ID - Type Unspecified