Provider Demographics
NPI:1881431864
Name:MOREAU, KIMBERLY MICHELLE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:MOREAU
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 1:3090 BRISTOL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3061
Mailing Address - Country:US
Mailing Address - Phone:888-789-9585
Mailing Address - Fax:562-803-4500
Practice Address - Street 1:3090 BRISTOL ST STE 200
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3061
Practice Address - Country:US
Practice Address - Phone:888-789-9585
Practice Address - Fax:562-803-4500
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95028797363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily