Healthcare Provider Details

I. General information

NPI: 1932203262
Provider Name (Legal Business Name): KIMBERLY COLLINS ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 MISSOURI BLVD STE B
GRAVOIS MILLS MO
65037-5394
US

IV. Provider business mailing address

54 HOSPITAL DR
OSAGE BEACH MO
65065-3050
US

V. Phone/Fax

Practice location:
  • Phone: 573-374-5263
  • Fax: 573-374-4933
Mailing address:
  • Phone: 573-348-8399
  • Fax: 573-348-8309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.004230
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number041208888
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: