Provider Demographics
NPI:1144468398
Name:FORD, KIM C (MSN,FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:C
Last Name:FORD
Suffix:
Gender:F
Credentials:MSN,FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 CANYON RD BUILDING B UNITE 2
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442
Mailing Address - Country:US
Mailing Address - Phone:928-444-1444
Mailing Address - Fax:928-444-1445
Practice Address - Street 1:2500 CANYON RD,
Practice Address - Street 2:BUILDING B UNITE 2
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442
Practice Address - Country:US
Practice Address - Phone:928-444-1444
Practice Address - Fax:928-444-1445
Is Sole Proprietor?:No
Enumeration Date:2009-01-27
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ468995Medicaid