Healthcare Provider Details

I. General information

NPI: 1831255744
Provider Name (Legal Business Name): KIMBERLEY JO ANDERSON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5302 W VILLAGE PKWY STE 3
ROGERS AR
72758-8139
US

IV. Provider business mailing address

2000 S PROMENADE BLVD STE 202
ROGERS AR
72758-8609
US

V. Phone/Fax

Practice location:
  • Phone: 479-372-4560
  • Fax: 877-461-6743
Mailing address:
  • Phone: 479-372-4560
  • Fax: 877-461-6743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberM002134
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberM002134
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: