Provider Demographics
NPI:1184456162
Name:PHILLIPS, KIMBERLY NICHOLE (FNP-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICHOLE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:LAIRSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN, RN
Mailing Address - Street 1:998 JOHNSON CORNER RD
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:GA
Mailing Address - Zip Code:30436-4810
Mailing Address - Country:US
Mailing Address - Phone:912-253-0211
Mailing Address - Fax:
Practice Address - Street 1:303 HARRIS INDUSTRIAL BLVD STE 3
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8854
Practice Address - Country:US
Practice Address - Phone:912-537-9355
Practice Address - Fax:912-335-4804
Is Sole Proprietor?:No
Enumeration Date:2024-08-17
Last Update Date:2024-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN236247363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner