Healthcare Provider Details

I. General information

NPI: 1649561788
Provider Name (Legal Business Name): KIMBERLY BONVILLAIN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2011
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROGRESS POINT PKWY STE 108
O FALLON MO
63368-2207
US

IV. Provider business mailing address

PO BOX 959354
SAINT LOUIS MO
63195-9354
US

V. Phone/Fax

Practice location:
  • Phone: 636-344-2400
  • Fax: 636-344-2401
Mailing address:
  • Phone: 636-344-2400
  • Fax: 636-344-2401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4008581
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2026019751
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.0035357
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number35357
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: