Basic Information
| Provider Information | |||||||||
| NPI: | 1275107351 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | KIMBERLIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10771 CANARY BLOSSOM AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891293341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6236984790 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1305 N MARTIN AVE | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857210001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206266154 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2021 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 838284 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.