Provider Demographics
NPI:1639414188
Name:ABSALOM, KACI (NP)
Entity Type:Individual
Prefix:MS
First Name:KACI
Middle Name:
Last Name:ABSALOM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5009 RIVERCHASE DR STE 500
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-7490
Mailing Address - Country:US
Mailing Address - Phone:334-448-9505
Mailing Address - Fax:334-448-9575
Practice Address - Street 1:5009 RIVERCHASE DR STE 500
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-7490
Practice Address - Country:US
Practice Address - Phone:334-448-9505
Practice Address - Fax:334-448-9575
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN177275363LF0000X
AL1-111962363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003138582Medicaid
AL167806Medicaid
GA202I508777Medicare PIN