MEDICARE: MS. KIMBERLY DENISE SOUZA FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	2014035648	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MA3251006	OTHER	MO	MEDICARE PROVIDER TRANSACTION ACCESS NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12803160	OTHER		CAQH

General Provider Information

NPI Number	:	1902200645
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMBERLY DENISE SOUZA FNP

Provider Business Mailing Address
First Line	:	PO BOX 1595
Second Line	:
City	:	MIDDLETOWN
State	:	CT
Zip	:	06457-8095
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 E COURT AVE STE 110
Second Line	:
City	:	DES MOINES
State	:	IA
Zip	:	50309-2027
Country	:	US
Telephone Number	:	860-788-6404
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2014
Last Update Date	:	09/04/2024

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