Healthcare Provider Details

I. General information

NPI: 1366210619
Provider Name (Legal Business Name): KIMBERLY MICHELLE COWLEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2023
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16501 PACIFIC COAST HWY
SUNSET BEACH CA
90742-2091
US

IV. Provider business mailing address

12601 EDGEMONT LN APT 43
GARDEN GROVE CA
92845-2963
US

V. Phone/Fax

Practice location:
  • Phone: 562-592-5100
  • Fax:
Mailing address:
  • Phone: 714-322-1564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95028583
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: