Provider Demographics
NPI:1891268991
Name:KAKOOZA, KIMBERLY FAUKE (APRN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:FAUKE
Last Name:KAKOOZA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 75TH ST
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-2325
Mailing Address - Country:US
Mailing Address - Phone:630-405-8892
Mailing Address - Fax:
Practice Address - Street 1:12850 S ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CALUMET PARK
Practice Address - State:IL
Practice Address - Zip Code:60827-6308
Practice Address - Country:US
Practice Address - Phone:708-972-7958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018538363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner