Provider Demographics
NPI:1619475571
Name:THOMPSON, KIMBERLY D (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:D
Other - Last Name:HUTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3105 MCCLELLAND BLVD.
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804
Mailing Address - Country:US
Mailing Address - Phone:417-347-5400
Mailing Address - Fax:417-347-0620
Practice Address - Street 1:3105 MCCLELLAND BLVD.
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-347-5400
Practice Address - Fax:417-347-0620
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018002580363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506033406Medicaid