Provider Demographics
NPI:1205249869
Name:PHILLIPS, KIMBERLY DAWN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3000
Mailing Address - Country:US
Mailing Address - Phone:334-792-5184
Mailing Address - Fax:
Practice Address - Street 1:1812 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3000
Practice Address - Country:US
Practice Address - Phone:334-792-5184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-074781363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily