Healthcare Provider Details

I. General information

NPI: 1942850862
Provider Name (Legal Business Name): KIMBERLI MAE HASTINGS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2019
Last Update Date: 12/31/2025
Certification Date: 12/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 N DEVON AVE
TEA SD
57064-2405
US

IV. Provider business mailing address

2520 N DEVON AVE
TEA SD
57064-2405
US

V. Phone/Fax

Practice location:
  • Phone: 509-240-5490
  • Fax:
Mailing address:
  • Phone: 509-240-5490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP001748
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2477350
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: