Provider Demographics
NPI:1043569437
Name:KLEAVELAND, KIMBERLY A (FNP)
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:A
Last Name:KLEAVELAND
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:A
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:
Practice Address - Street 1:3525 E LOUISE DR STE 500
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6305
Practice Address - Country:US
Practice Address - Phone:208-706-7050
Practice Address - Fax:208-706-7059
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201505347NP-PP363LF0000X
ID66267363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEP01213775Medicare PIN
ME002941302Medicare PIN
ME002941301Medicare PIN