=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861932253
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLYNE KIMELI-MBARAKA APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2017
-----------------------------------------------------
Last Update Date | 01/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9119 HIGHWAY 6 STE 230379
-----------------------------------------------------
City | MISSOURI CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77459-4876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-645-0105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9119 HIGHWAY 6 STE 230379
-----------------------------------------------------
City | MISSOURI CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77459-4876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-645-0105
-----------------------------------------------------
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 | 3011157
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 3011157
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 10016612
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------