Provider Demographics
NPI:1700267994
Name:WAHL, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WAHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S HOUSTON LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-9006
Mailing Address - Country:US
Mailing Address - Phone:478-955-1592
Mailing Address - Fax:
Practice Address - Street 1:200 S HOUSTON LAKE RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-9006
Practice Address - Country:US
Practice Address - Phone:478-953-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN208988363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF0515490OtherCERTIFICATION NUMBER (AMERICAN ACADEMY NURSE PRACTITIONERS)
GARN208988OtherGA STATE NURSE PRACTITIONER LICENSURE