Provider Demographics
NPI:1639208333
Name:STONE, KEMBERLY AMANDA (PA-C)
Entity Type:Individual
Prefix:
First Name:KEMBERLY
Middle Name:AMANDA
Last Name:STONE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 LAKES BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31636-6607
Mailing Address - Country:US
Mailing Address - Phone:229-588-2866
Mailing Address - Fax:
Practice Address - Street 1:453 LAKES BLVD SUITE B
Practice Address - Street 2:LAKE PARK FAMILY CARE CLINIC
Practice Address - City:LAKE PARK
Practice Address - State:GA
Practice Address - Zip Code:31636
Practice Address - Country:US
Practice Address - Phone:229-588-2866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA05480363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA05480OtherGEORGIA MEDICAL LICENSE NUMBER: 05480 EXPIRATION 01/31/2016