Provider Demographics
NPI:1720451297
Name:MITCHAM, KIMBERLY DAWN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:MITCHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 S MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-0161
Mailing Address - Country:US
Mailing Address - Phone:912-367-2596
Mailing Address - Fax:912-367-8706
Practice Address - Street 1:950 S MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0161
Practice Address - Country:US
Practice Address - Phone:912-367-2596
Practice Address - Fax:912-367-8706
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN149433NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily