1881928315 NPI number — MRS. KIMBERLY OWEN LOE NURSE PRACTITIONER

Table of content: MRS. KIMBERLY OWEN LOE NURSE PRACTITIONER (NPI 1881928315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881928315 NPI number — MRS. KIMBERLY OWEN LOE NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOE
Provider First Name:
KIMBERLY
Provider Middle Name:
OWEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881928315
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23666
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39225-3666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-200-4880
Provider Business Mailing Address Fax Number:
601-200-0988

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4290 LAKELAND DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-9571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-932-0083
Provider Business Practice Location Address Fax Number:
601-932-8124
Provider Enumeration Date:
09/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R862120 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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