Healthcare Provider Details

I. General information

NPI: 1770964728
Provider Name (Legal Business Name): KIMBERLY R HENRIQUES APRN-AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 HERRICK STREET
BEVERLY MA
01915
US

IV. Provider business mailing address

85 HERRICK STREET
BEVERLY MA
01915
US

V. Phone/Fax

Practice location:
  • Phone: 978-922-3000
  • Fax:
Mailing address:
  • Phone: 978-922-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2292104
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberCNP151201
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN64322
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: