Provider Demographics
NPI:1548365430
Name:REISENWITZ, KIMBERLY V (CRNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:V
Last Name:REISENWITZ
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1958 CARTER GROVE RD
Mailing Address - Street 2:
Mailing Address - City:HAZEL GREEN
Mailing Address - State:AL
Mailing Address - Zip Code:35750-8327
Mailing Address - Country:US
Mailing Address - Phone:256-828-1695
Mailing Address - Fax:
Practice Address - Street 1:4030 PEPPERWOOD CIR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6499
Practice Address - Country:US
Practice Address - Phone:256-539-6536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1055707363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51536198OtherBCBS OF ALABAMA
AL51554692Medicare ID - Type Unspecified