Provider Demographics
NPI:1902200645
Name:SOUZA, KIMBERLY DENISE (FNP)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:DENISE
Last Name:SOUZA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 SOUTH HWY. 32
Mailing Address - Street 2:
Mailing Address - City:EL DORADO SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64744
Mailing Address - Country:US
Mailing Address - Phone:417-876-3333
Mailing Address - Fax:417-876-4509
Practice Address - Street 1:1317 SOUTH HWY. 32
Practice Address - Street 2:
Practice Address - City:EL DORADO SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64744
Practice Address - Country:US
Practice Address - Phone:417-876-3333
Practice Address - Fax:417-876-4509
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014035648363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA3251006OtherMEDICARE PROVIDER TRANSACTION ACCESS NUMBER
12803160OtherCAQH