Provider Demographics
NPI:1013359934
Name:BOOKER, KIMBERLY RANDALL (CNM, WHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:RANDALL
Last Name:BOOKER
Suffix:
Gender:F
Credentials:CNM, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3871 VANCE STREET EXT
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-8873
Mailing Address - Country:US
Mailing Address - Phone:336-613-0904
Mailing Address - Fax:
Practice Address - Street 1:520 MAPLE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-4652
Practice Address - Country:US
Practice Address - Phone:336-342-6063
Practice Address - Fax:336-342-6066
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCBOO104379455363LW0102X
NC522367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1799GOtherBCBS
Q44206AOtherMEDICARE INDIVIDUAL PTAN LINKED TO FACULTY PRACTICE GROUP
NC1013359934Medicaid
Q44206D411Medicare PIN