Healthcare Provider Details

I. General information

NPI: 1871473876
Provider Name (Legal Business Name): DAIZAH RAYE KIMBERLAND FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2025
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 PARKWAY DR
BARDSTOWN KY
40004-3220
US

IV. Provider business mailing address

141 PARKWAY DR
BARDSTOWN KY
40004-3220
US

V. Phone/Fax

Practice location:
  • Phone: 502-348-4757
  • Fax: 502-348-4755
Mailing address:
  • Phone: 502-348-4757
  • Fax: 502-348-4755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4044398
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: