Provider Demographics
NPI:1811982127
Name:KIRK, GINA (FNP)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:
Last Name:KIRK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HWY 49 S
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008-6937
Mailing Address - Country:US
Mailing Address - Phone:478-956-2648
Mailing Address - Fax:478-956-4080
Practice Address - Street 1:200 HWY 49 S
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:GA
Practice Address - Zip Code:31008-6937
Practice Address - Country:US
Practice Address - Phone:478-956-2648
Practice Address - Fax:478-956-4080
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN119650NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00958856BMedicaid
GA50BBKDVMedicare PIN
GA00958856BMedicaid