Healthcare Provider Details

I. General information

NPI: 1891268991
Provider Name (Legal Business Name): KIMBERLY FAUKE KAKOOZA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N HUMPHREYS ST STE 104
FLAGSTAFF AZ
86001-3124
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 928-779-3844
  • Fax:
Mailing address:
  • Phone: 847-570-2040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277002831
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.018538
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number337491
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: