Provider Demographics
NPI:1124323456
Name:MLCAK, KIM MARIE (GNP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:MLCAK
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 FM 517 RD W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:TX
Mailing Address - Zip Code:77539-3904
Mailing Address - Country:US
Mailing Address - Phone:281-218-7200
Mailing Address - Fax:281-218-7203
Practice Address - Street 1:680 FM 517 RD W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:TX
Practice Address - Zip Code:77539-3904
Practice Address - Country:US
Practice Address - Phone:281-218-7200
Practice Address - Fax:281-218-7203
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX244803363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology