Provider Demographics
NPI:1487034849
Name:MCCLOUD, KIMBERLY ANNE (MSN, FNP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:MCCLOUD
Suffix:
Gender:F
Credentials:MSN, FNP
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 490
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-0490
Mailing Address - Country:US
Mailing Address - Phone:601-250-4366
Mailing Address - Fax:
Practice Address - Street 1:1167 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654-7682
Practice Address - Country:US
Practice Address - Phone:601-587-1433
Practice Address - Fax:601-587-1625
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR874765363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09501028Medicaid
MS09501028Medicaid