Provider Demographics
NPI:1477334415
Name:MICKENS, KIMBERLY NATASHIA
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NATASHIA
Last Name:MICKENS
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 1:502 NORTHLANDS LN
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-6695
Mailing Address - Country:US
Mailing Address - Phone:706-338-8350
Mailing Address - Fax:
Practice Address - Street 1:275A THOMSON RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:GA
Practice Address - Zip Code:30673-4313
Practice Address - Country:US
Practice Address - Phone:706-338-8350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN099093164W00000X, 251E00000X, 251J00000X, 261QD1600X, 385HR2060X, 251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child