Provider Demographics
NPI:1902058977
Name:MOULLIET, KIMBERLY ANNE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:MOULLIET
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3835 S JONES BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-2283
Mailing Address - Country:US
Mailing Address - Phone:702-570-9050
Mailing Address - Fax:
Practice Address - Street 1:3835 S JONES BLVD STE 104
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-2283
Practice Address - Country:US
Practice Address - Phone:775-570-9050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV700465363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily