Healthcare Provider Details

I. General information

NPI: 1346509288
Provider Name (Legal Business Name): KIMBERLEY ROBERTS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2012
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W MARKET ST
BLOOMINGTON IL
61701-3918
US

IV. Provider business mailing address

108 W MARKET ST
BLOOMINGTON IL
61701-3918
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-5351
  • Fax:
Mailing address:
  • Phone: 309-827-5351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number041491402
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number808374
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: