Provider Demographics
NPI:1174580245
Name:DRAKE, KIMBERLY A (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:DRAKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 BARATARIA BLVD
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3044
Mailing Address - Country:US
Mailing Address - Phone:504-349-6401
Mailing Address - Fax:
Practice Address - Street 1:1151 BARATARIA BLVD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3044
Practice Address - Country:US
Practice Address - Phone:504-349-6401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905286363LA2200X, 363LF0000X
LARN061743363LF0000X
LAAP04449363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05809264Medicaid
LA1461083Medicaid
MS05809264Medicaid
LA4H142Medicare PIN
Q24789Medicare UPIN