Provider Demographics
NPI:1003207101
Name:CALDWELL, KIMBERLY ANNE (CSFA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-1750
Mailing Address - Country:US
Mailing Address - Phone:864-871-1644
Mailing Address - Fax:
Practice Address - Street 1:306 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-1750
Practice Address - Country:US
Practice Address - Phone:864-871-1644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-10
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZC0007X
SC363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant