Basic Information
| Provider Information | |||||||||
| NPI: | 1003294828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLAKE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 S ROLES DR | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852968605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802161837 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1020 S ROLES DR | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852968605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802161837 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2015 | ||||||||
| LastUpdateDate: | 05/13/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LX0001X | AP7625 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
No ID Information.