1174776173 NPI number — MRS. KIMBERLEY JEAN ROBERTS WHNP

Table of content: MRS. KIMBERLEY JEAN ROBERTS WHNP (NPI 1174776173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174776173 NPI number — MRS. KIMBERLEY JEAN ROBERTS WHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
KIMBERLEY
Provider Middle Name:
JEAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
WHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174776173
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9305 W THOMAS RD
Provider Second Line Business Mailing Address:
SUITE 155
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85037-3328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-936-1780
Provider Business Mailing Address Fax Number:
623-936-9116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9305 W THOMAS RD
Provider Second Line Business Practice Location Address:
SUITE 155
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85037-3328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-936-1780
Provider Business Practice Location Address Fax Number:
623-936-9116
Provider Enumeration Date:
11/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LW0102X , with the licence number:  AP2825 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Z143364 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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