Healthcare Provider Details

I. General information

NPI: 1720461924
Provider Name (Legal Business Name): KIMBERLY ROBERTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724 STATE ST
NEW ALBANY IN
47150
US

IV. Provider business mailing address

9510 ORMSBY STATION RD STE 100
LOUISVILLE KY
40223-4082
US

V. Phone/Fax

Practice location:
  • Phone: 866-460-3567
  • Fax: 855-632-8329
Mailing address:
  • Phone: 502-327-9100
  • Fax: 855-632-8329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71005564A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: