Provider Demographics
NPI:1134988520
Name:BOUMAN, KIMBERLY SUZANNE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUZANNE
Last Name:BOUMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 W COAST HWY STE I
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4732
Mailing Address - Country:US
Mailing Address - Phone:949-723-0044
Mailing Address - Fax:
Practice Address - Street 1:2400 W COAST HWY STE I
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4732
Practice Address - Country:US
Practice Address - Phone:949-723-0044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty