Provider Demographics
NPI:1063621183
Name:EARLEY, KIMMIE MEDINA
Entity type:Individual
Prefix:MRS
First Name:KIMMIE
Middle Name:MEDINA
Last Name:EARLEY
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 1:6408 PALMETTO POINTE DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-8823
Mailing Address - Country:US
Mailing Address - Phone:910-616-9446
Mailing Address - Fax:
Practice Address - Street 1:6408 PALMETTO POINTE DR
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-8823
Practice Address - Country:US
Practice Address - Phone:910-616-9446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2019-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1342106H00000X
MST0509106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist