Basic Information
| Provider Information | |||||||||
| NPI: | 1679510390 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EBERSOL | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | A.P.R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 843966 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641843966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738843300 | ||||||||
| FaxNumber: | 5738840943 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 N KEENE ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738823961 | ||||||||
| FaxNumber: | 5738844277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 09/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 123260 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364SP0200X | 123260 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Pediatrics | 363LP0200X | 123260 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 693696 | 01 | MO | HEALTHLINK | OTHER | 195637 | 01 | MO | BLUE SHIELD/BLUE CHOICE | OTHER | 429459506 | 05 | MO | MEDICAID |