Provider Demographics
NPI:1407460157
Name:LACAP, KIMBERLY N
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:N
Last Name:LACAP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:N
Other - Last Name:BODIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15190 COMMUNITY RD STE 230
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3483
Mailing Address - Country:US
Mailing Address - Phone:228-206-1283
Mailing Address - Fax:
Practice Address - Street 1:15190 COMMUNITY RD STE 230
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3483
Practice Address - Country:US
Practice Address - Phone:228-206-1283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904594363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily