MEDICARE: KIM SICKELS NURSE PRACTITIONER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	4488P	KY
2	363LA2200X	Adult Health Nurse Practitioner	71000724A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00410	OTHER	KY	MEDICARE GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447469580
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIM SICKELS NURSE PRACTITIONER, LLC

Provider Business Mailing Address
First Line	:	3103 HERITAGE HEIGHTS WAY
Second Line	:
City	:	JEFFERSONVILLE
State	:	IN
Zip	:	47130-8934
Country	:	US
Telephone Number	:	502-939-9754
Fax Number	:	812-284-6550

Provider Business Practice Location Address
First Line	:	3103 HERITAGE HEIGHTS WAY
Second Line	:
City	:	JEFFERSONVILLE
State	:	IN
Zip	:	47130-8934
Country	:	US
Telephone Number	:	502-939-9754
Fax Number	:	812-284-6550

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	KIM ANNETTE SICKELS
Credential	:	NURSE PRACTITIONER
Telephone Number	:	502-939-9754

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	12/05/2007

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Directions to “KIM SICKELS NURSE PRACTITIONER, LLC ” Practice Location

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