Provider Demographics
NPI:1558804971
Name:PROCTOR, KACIE MIRANDA (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:KACIE
Middle Name:MIRANDA
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MISS
Other - First Name:KACIE
Other - Middle Name:MIRANDA
Other - Last Name:MINTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:304 TURNER MCCALL BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-5621
Mailing Address - Country:US
Mailing Address - Phone:706-509-5000
Mailing Address - Fax:
Practice Address - Street 1:304 TURNER MCCALL BLVD SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-5621
Practice Address - Country:US
Practice Address - Phone:706-509-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-02
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN230749163WE0003X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency