Provider Demographics
NPI:1760617005
Name:KINKADE, KIMBERLY MARIE (APRN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:KINKADE
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4975 LACROSS RD STE 150
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-6531
Mailing Address - Country:US
Mailing Address - Phone:843-737-9467
Mailing Address - Fax:
Practice Address - Street 1:2067 CHARLIE HALL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5834
Practice Address - Country:US
Practice Address - Phone:843-573-2535
Practice Address - Fax:843-573-2534
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001240478363LF0000X
SC25520363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1760617005Medicaid
SCNP7962Medicaid
175150023OtherMEDICARE