Provider Demographics
NPI:1447361175
Name:KING, KIMBERLY LYNN (FNP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LYNN
Last Name:KING
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:LYNN
Other - Last Name:PONDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 66308
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77266-6308
Mailing Address - Country:US
Mailing Address - Phone:832-548-5000
Mailing Address - Fax:
Practice Address - Street 1:4450 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77705
Practice Address - Country:US
Practice Address - Phone:832-548-5000
Practice Address - Fax:409-242-2526
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP114235363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
741809OtherLEGACY COMMUNITY HEALTH SERVICES INC SITE SPECIFIC MEDICARE
TX080462703OtherLEGACY COMMUNITY HEALTH SERVICES, INC. MEDICAID NUMBER
TXAP114235OtherTEXAS NURSING LICENSE