Provider Demographics
NPI:1043429202
Name:BURGESS, KIMBERLY ANN (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:ANN
Last Name:BURGESS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 OLD COWAN RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37398-1913
Mailing Address - Country:US
Mailing Address - Phone:931-962-1004
Mailing Address - Fax:931-962-1400
Practice Address - Street 1:2656 BLUE CYPRESS LAKE CT
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2912
Practice Address - Country:US
Practice Address - Phone:954-448-5636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3292363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant