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General NPI Number Information
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NPI Number | 1891422853
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Entity Type | Individual
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Provider Name | KIMBERLIE LA'TASHA MABRY FNP-C
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Gender | Female
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Dates
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Enumeration Date | 08/01/2022
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Last Update Date | 07/18/2023
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Provider Practice Location Address
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Address Line | 1509 WILLOWBEND DR
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City | GAUTIER
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State | MS
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Zip | 39553-7627
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Country | US
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Telephone | 228-627-1223
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Fax |
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Provider Business Mailing Address
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Address Line | 1509 WILLOWBEND DR
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City | GAUTIER
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State | MS
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Zip | 39553-7627
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Country | US
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Telephone | 228-627-1223
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 905478
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 227359
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License Number State | LA
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 905478
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License Number State | MS
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