Provider Demographics
NPI:1275824088
Name:GONZALES, KIMBERLY ROGERS (ACNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ROGERS
Last Name:GONZALES
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ROGERS
Other - Last Name:SHOWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNP
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-288-4329
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-288-4329
Practice Address - Fax:601-579-5240
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR813989363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07805026Medicaid
MS30250I8700Medicare PIN
MS07805026Medicaid