Provider Demographics
NPI:1437224615
Name:PICKETT, KIM ANNE (PHD, APRN)
Entity Type:Individual
Prefix:PROF
First Name:KIM
Middle Name:ANNE
Last Name:PICKETT
Suffix:
Gender:F
Credentials:PHD, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8617
Mailing Address - Fax:
Practice Address - Street 1:877 W FARIS RD STE D
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4296
Practice Address - Country:US
Practice Address - Phone:864-455-9031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17491363LF0000X, 363L00000X
OHNP07598363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1908Medicaid
NC7006002Medicaid
SCP01001850OtherRAILROAD MEDICARE
SCSC72645019OtherMEDICARE PIN
SCSC72643365Medicare PIN
SCAA76476067Medicare PIN