Provider Demographics
NPI:1578080784
Name:BENNETT, KIMBLEY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KIMBLEY
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-1525
Mailing Address - Country:US
Mailing Address - Phone:706-596-1245
Mailing Address - Fax:706-576-4245
Practice Address - Street 1:1942 NORTH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1525
Practice Address - Country:US
Practice Address - Phone:706-596-1245
Practice Address - Fax:706-576-4245
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN183629363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner