Basic Information
| Provider Information | |||||||||
| NPI: | 1568874998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 806 JEFFERSON TER | ||||||||
| Address2: | |||||||||
| City: | NEW IBERIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705605727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373654945 | ||||||||
| FaxNumber: | 3373766860 | ||||||||
| Practice Location | |||||||||
| Address1: | 1004 SURREY ST | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705016143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374566768 | ||||||||
| FaxNumber: | 3374568690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2014 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP07726 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2365576 | 05 | LA | MEDICAID |