Provider Demographics
NPI:1184367377
Name:BALIE, KIMBERLY (RPSGT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BALIE
Suffix:
Gender:F
Credentials:RPSGT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPSGT
Mailing Address - Street 1:300 LONDON LN
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-5455
Mailing Address - Country:US
Mailing Address - Phone:828-980-4817
Mailing Address - Fax:
Practice Address - Street 1:2540 WINDY HILL RD SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8605
Practice Address - Country:US
Practice Address - Phone:470-644-1778
Practice Address - Fax:770-644-1759
Is Sole Proprietor?:No
Enumeration Date:2022-04-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
11153246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other