=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588121230
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLEMENT KEZIMANA NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2019
-----------------------------------------------------
Last Update Date | 02/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | PRIMARY AND URGENT CARE LLC 2306 PLANK ROAD
-----------------------------------------------------
City | FEDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-785-9900
-----------------------------------------------------
Fax | 540-785-9960
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3910
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22402-3910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-785-9900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 0024177049
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------