Provider Demographics
NPI:1487856092
Name:CONNALLY, KIMBERLY MILLER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MILLER
Last Name:CONNALLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:MILLER
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1150 BROOKSTONE CENTRE PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-4577
Mailing Address - Country:US
Mailing Address - Phone:706-257-4189
Mailing Address - Fax:706-257-4194
Practice Address - Street 1:1150 BROOKSTONE CENTRE PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-4577
Practice Address - Country:US
Practice Address - Phone:706-257-4189
Practice Address - Fax:706-257-4194
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1561363A00000X, 363A00000X
GA5065363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA3400242858Medicaid
GA511I970127Medicare PIN