Basic Information
| Provider Information | |||||||||
| NPI: | 1538708003 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TITAK | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30388 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852750388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808303902 | ||||||||
| FaxNumber: | 4808303901 | ||||||||
| Practice Location | |||||||||
| Address1: | 4555 E INVERNESS AVE | ||||||||
| Address2: | STE 112 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803610110 | ||||||||
| FaxNumber: | 4808303901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2020 | ||||||||
| LastUpdateDate: | 12/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 263215 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 209020467 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.