Basic Information
| Provider Information | |||||||||
| NPI: | 1740203041 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABBOTT | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17609 OLD JEFFERSON HWY | ||||||||
| Address2: | |||||||||
| City: | PRAIRIEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707695242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256779595 | ||||||||
| FaxNumber: | 2256779695 | ||||||||
| Practice Location | |||||||||
| Address1: | 17609 OLD JEFFERSON HWY STE D | ||||||||
| Address2: | |||||||||
| City: | PRAIRIEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707693980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257655500 | ||||||||
| FaxNumber: | 2256779695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN089741 AP1480 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1583294 | 05 | LA | MEDICAID |