Healthcare Provider Details

I. General information

NPI: 1851828511
Provider Name (Legal Business Name): KIMBERLLY JOY STEVENS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 04/26/2025
Certification Date: 04/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 NE BROADWAY ST
MYRTLE CREEK OR
97457-9039
US

IV. Provider business mailing address

2589 NW EDENBOWER BLVD
ROSEBURG OR
97471-6224
US

V. Phone/Fax

Practice location:
  • Phone: 541-677-7200
  • Fax: 541-229-3309
Mailing address:
  • Phone: 541-839-1345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201703307NP-PP
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500725333
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: