Provider Demographics
NPI:1639359276
Name:MIMS, KIMBERLY NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:MIMS
Suffix:
Gender:F
Credentials:MD
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3030 RANDOLPH RD
Practice Address - Street 2:STE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1368
Practice Address - Country:US
Practice Address - Phone:704-302-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-012112084N0400X, 2084N0600X, 2084S0012X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1639359276Medicaid
SCNC1842Medicaid
NCNCE754AMedicare PIN
NCNCE754BMedicare PIN