Provider Demographics
NPI:1144603648
Name:TRAMMELL, KIMBERLY (AGNP-BC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:TRAMMELL
Suffix:
Gender:F
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:GILLESPIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGNP-BC
Mailing Address - Street 1:PO BOX 538622
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-8622
Mailing Address - Country:US
Mailing Address - Phone:910-742-9243
Mailing Address - Fax:888-746-1787
Practice Address - Street 1:2101 DUTCH FORK RD
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-7576
Practice Address - Country:US
Practice Address - Phone:910-742-9243
Practice Address - Fax:888-746-1787
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19579363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC6012C473Medicare PIN