Provider Demographics
NPI:1992034367
Name:HITCHCOCK, KIMBERLIE MARIE (GRNA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLIE
Middle Name:MARIE
Last Name:HITCHCOCK
Suffix:
Gender:F
Credentials:GRNA
Other - Prefix:MISS
Other - First Name:KIMBERLIE
Other - Middle Name:MARIE
Other - Last Name:CHANDLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1792
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-1792
Mailing Address - Country:US
Mailing Address - Phone:843-692-1062
Mailing Address - Fax:
Practice Address - Street 1:809 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-692-1062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4085367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered