Provider Demographics
NPI:1174563241
Name:BEGALLA, KIMBERLY ANNE (CFNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:BEGALLA
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1382
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82931-1382
Mailing Address - Country:US
Mailing Address - Phone:307-789-6111
Mailing Address - Fax:307-789-7111
Practice Address - Street 1:75 YELLOW CREEK RD
Practice Address - Street 2:SUITE 202
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5235
Practice Address - Country:US
Practice Address - Phone:307-789-6111
Practice Address - Fax:307-789-7111
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY19196.0204363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118122000Medicaid