Provider Demographics
NPI:1578984951
Name:SAMUEL, KIMBERLY (FNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 WOLVERINE DR SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4933
Mailing Address - Country:US
Mailing Address - Phone:256-333-1997
Mailing Address - Fax:256-303-5007
Practice Address - Street 1:1625 WOLVERINE DR SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4933
Practice Address - Country:US
Practice Address - Phone:256-333-1997
Practice Address - Fax:256-303-5007
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-02
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-120233363LF0000X
AL1120233363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily