Provider Demographics
NPI:1801368741
Name:GROSS, KIMBERLY JOHNSON (FNP, PMHNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JOHNSON
Last Name:GROSS
Suffix:
Gender:F
Credentials:FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7215 S SIWELL RD
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-9776
Mailing Address - Country:US
Mailing Address - Phone:601-373-2204
Mailing Address - Fax:601-373-4413
Practice Address - Street 1:348 CROSSGATES BLVD STE 1500
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2687
Practice Address - Country:US
Practice Address - Phone:601-824-2236
Practice Address - Fax:601-825-2699
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS875256363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily