Kimberly Broussard

Primary specialty

Preferred Provider OrganizationTaxonomy code 305R00000X

Legal business name

KIMBERLY BROUSSARD

Practice address

3380 E Russell Rd
Suite 104
Las Vegas, NV 89120-3402

Phone

(702) 476-0448

Fax

(702) 476-0449

NPI assigned

Apr 28, 2016

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Kimberly Rashone Broussard

Title

Owner / Operator

Phone

(702) 807-1718

Specialties & licenses 2

Addresses

Other names 1

• PHENOMENAL ANGELS Doing business as

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1461801600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1461888000000",
    "number": "1477908275",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3380 E RUSSELL RD",
            "address_2": "SUITE 104",
            "city": "LAS VEGAS",
            "state": "NV",
            "postal_code": "891203402",
            "telephone_number": "702-476-0448",
            "fax_number": "702-476-0449"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3380 E RUSSELL RD",
            "address_2": "SUITE 104",
            "city": "LAS VEGAS",
            "state": "NV",
            "postal_code": "891203402",
            "telephone_number": "702-476-0448",
            "fax_number": "702-476-0449"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KIMBERLY BROUSSARD",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-04-28",
        "last_updated": "2016-04-29",
        "status": "A",
        "authorized_official_last_name": "BROUSSARD",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_middle_name": "RASHONE",
        "authorized_official_title_or_position": "OWNER / OPERATOR",
        "authorized_official_telephone_number": "702-807-1718",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "103K00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Behavior Analyst",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "305R00000X",
            "taxonomy_group": "",
            "desc": "Preferred Provider Organization",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PHENOMENAL ANGELS",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Constance Anne Kimball
• Koree Kimball, PTA
• Kyle Kimball
• Jimmy Kimber, PHARMD
• Kimberly a Adams MD PC
• Kimberly Lathan Therapy LLC
• Kimberly Molnar MFT LTD
• Kimberly N. Beeman, PT, DPT, PLLC
• Kimberly P Yap DDS PC
• Beth Kimberly

• Preferred Provider Organization in Las Vegas, NV
• Providers in Las Vegas, NV by specialty
• Preferred Provider Organization in Nevada

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 29, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; OIG LEIE.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.