Provider Demographics
NPI:1447469580
Name:KIM SICKELS NURSE PRACTITIONER, LLC
Entity type:Organization
Organization Name:KIM SICKELS NURSE PRACTITIONER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:SICKELS
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:502-939-9754
Mailing Address - Street 1:3103 HERITAGE HEIGHTS WAY
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-8934
Mailing Address - Country:US
Mailing Address - Phone:502-939-9754
Mailing Address - Fax:812-284-6550
Practice Address - Street 1:3103 HERITAGE HEIGHTS WAY
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-8934
Practice Address - Country:US
Practice Address - Phone:502-939-9754
Practice Address - Fax:812-284-6550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000724A363LA2200X
KY4488P363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00410OtherMEDICARE GROUP
KY78007168Medicaid
IN200222290BMedicaid
IN200222290BMedicaid