Healthcare Provider Details

I. General information

NPI: 1104537489
Provider Name (Legal Business Name): KIMBERLY WELLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2022
Last Update Date: 12/08/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 N 7TH AVE
BROKEN BOW NE
68822-1718
US

IV. Provider business mailing address

323 N 7TH AVE
BROKEN BOW NE
68822-1718
US

V. Phone/Fax

Practice location:
  • Phone: 308-872-6821
  • Fax:
Mailing address:
  • Phone: 308-872-6821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number55759
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: