Provider Demographics
NPI:1275037186
Name:PHILLIPS, KIMBERLY VICKERY (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:VICKERY
Last Name:PHILLIPS
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 1:11512 LAKE MEAD AVE UNIT 536
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9733
Mailing Address - Country:US
Mailing Address - Phone:904-222-6103
Mailing Address - Fax:
Practice Address - Street 1:11512 LAKE MEAD AVE UNIT 536
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9733
Practice Address - Country:US
Practice Address - Phone:904-222-6103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2023-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN266565363L00000X
FL11021946363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner