Provider Demographics
NPI:1376714667
Name:GHOLAR, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GHOLAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 177
Mailing Address - Street 2:
Mailing Address - City:PRENTISS
Mailing Address - State:MS
Mailing Address - Zip Code:39474-0177
Mailing Address - Country:US
Mailing Address - Phone:601-441-3537
Mailing Address - Fax:601-792-0664
Practice Address - Street 1:1814 COLUMBIA AVE STE B
Practice Address - Street 2:
Practice Address - City:PRENTISS
Practice Address - State:MS
Practice Address - Zip Code:39474-0177
Practice Address - Country:US
Practice Address - Phone:601-792-0664
Practice Address - Fax:844-274-1342
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-14
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No171400000XOther Service ProvidersHealth & Wellness Coach
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02837348Medicaid
MS09559043Medicaid