Provider Demographics
NPI:1093180481
Name:ANDERSON, KYMBERLY D (NP)
Entity Type:Individual
Prefix:
First Name:KYMBERLY
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:GA
Mailing Address - Zip Code:31510-2908
Mailing Address - Country:US
Mailing Address - Phone:912-632-2952
Mailing Address - Fax:
Practice Address - Street 1:204 E 15TH ST
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:GA
Practice Address - Zip Code:31510-2908
Practice Address - Country:US
Practice Address - Phone:912-632-2952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN149756363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I509677OtherMEDICARE PTAN
GA003174390AMedicaid