Healthcare Provider Details

I. General information

NPI: 1962818666
Provider Name (Legal Business Name): KAITLYN ELIZABETH ZIMMER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 W SYCAMORE ST
KOKOMO IN
46901-4197
US

IV. Provider business mailing address

1431 CENTERPOINT BLVD SUITE 100
KNOXVILLE TN
37932-1983
US

V. Phone/Fax

Practice location:
  • Phone: 765-456-5360
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10001676A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001676A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: