Provider Demographics
NPI:1164972055
Name:SCOTT, KIMBERLY (APRN-BC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8558 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7032
Mailing Address - Country:US
Mailing Address - Phone:219-392-7084
Mailing Address - Fax:219-703-6854
Practice Address - Street 1:9112 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2925
Practice Address - Country:US
Practice Address - Phone:219-836-5040
Practice Address - Fax:219-836-6835
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.014787363LF0000X
IN71015908A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300098151Medicaid