Healthcare Provider Details

I. General information

NPI: 1720090947
Provider Name (Legal Business Name): KIMBERLY MELLENCAMP FREEMAN C.N.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 18TH ST SUITE 210
COLUMBUS IN
47201-5388
US

IV. Provider business mailing address

2325 18TH ST SUITE 210
COLUMBUS IN
47201-5388
US

V. Phone/Fax

Practice location:
  • Phone: 812-375-0272
  • Fax: 812-375-1093
Mailing address:
  • Phone: 812-375-0272
  • Fax: 812-375-1093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number28116944A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: