Provider Demographics
NPI:1679740708
Name:KIMBROUGH, FELICIA DESHA (FNP BC)
Entity type:Individual
Prefix:MRS
First Name:FELICIA
Middle Name:DESHA
Last Name:KIMBROUGH
Suffix:
Gender:F
Credentials:FNP BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-1923
Mailing Address - Country:US
Mailing Address - Phone:618-985-8221
Mailing Address - Fax:618-985-6860
Practice Address - Street 1:1301 E WALNUT ST RM J120
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5004
Practice Address - Country:US
Practice Address - Phone:618-519-9200
Practice Address - Fax:618-457-8931
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007991363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL406333266001Medicaid
IL370966854002Medicaid
IL370966854005Medicaid
ILCF3444OtherMEDICARE RR
IL141840Medicare Oscar/Certification
IL640701Medicare Oscar/Certification
IL141848Medicare Oscar/Certification