Provider Demographics
NPI:1053784009
Name:VANDALEN, KIMBERLY CAROL
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CAROL
Last Name:VANDALEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 S PROGRESS DR
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-2673
Mailing Address - Country:US
Mailing Address - Phone:937-372-7583
Mailing Address - Fax:
Practice Address - Street 1:193 S PROGRESS DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2673
Practice Address - Country:US
Practice Address - Phone:937-372-7583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-12
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025839363LF0000X
TXAP1296102083P0901X, 207Q00000X, 208D00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0389946Medicaid
TX083850001Medicaid
TX017801401Medicaid
TX063389301Medicaid
TX87V600OtherBCBS
TX87V601OtherBCBS
TXAP129610OtherTEXAS STATE LICENSE
TX017801401Medicaid