Provider Demographics
NPI:1578733986
Name:RAYBORN, KIMBERLY P (NPC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:P
Last Name:RAYBORN
Suffix:
Gender:F
Credentials:NPC
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 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-864-8454
Mailing Address - Fax:228-865-1457
Practice Address - Street 1:394 COURTHOUSE RD
Practice Address - Street 2:SUITE A
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-1865
Practice Address - Country:US
Practice Address - Phone:228-896-4417
Practice Address - Fax:228-604-0121
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR867582363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04709739Medicaid
MS302I505960Medicare PIN
MS302I506679Medicare PIN