Provider Demographics
NPI:1063007789
Name:ZICKAFOOSE, KIMBERLY (WHNP-BC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ZICKAFOOSE
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12602 TOEPPERWEIN RD STE 208
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3271
Mailing Address - Country:US
Mailing Address - Phone:210-878-0090
Mailing Address - Fax:
Practice Address - Street 1:12602 TOEPPERWEIN RD STE 208
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3271
Practice Address - Country:US
Practice Address - Phone:210-878-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX909383363LF0000X
TX1077936363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily