Basic Information
| Provider Information | |||||||||
| NPI: | 1316387764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | DAWN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1080 | ||||||||
| Address2: | |||||||||
| City: | BURKESVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427171080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708641472 | ||||||||
| FaxNumber: | 2708641693 | ||||||||
| Practice Location | |||||||||
| Address1: | 512 SAFFELL ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403421253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022272229 | ||||||||
| FaxNumber: | 5022271114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2013 | ||||||||
| LastUpdateDate: | 06/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3008104 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 700172 | 01 | KY | STATE LICENSE | OTHER | 7100017280 | 05 | KY | MEDICAID |