Healthcare Provider Details

I. General information

NPI: 1518281757
Provider Name (Legal Business Name): KIMBERLY A NIEBRUGGE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2010
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 N 8TH ST
VANDALIA IL
62471-1238
US

IV. Provider business mailing address

1029 N 8TH ST
VANDALIA IL
62471-1238
US

V. Phone/Fax

Practice location:
  • Phone: 618-283-4469
  • Fax: 618-283-4767
Mailing address:
  • Phone: 618-283-4469
  • Fax: 618-283-4767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number200932407
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209-007693
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: