Provider Demographics
NPI:1104505460
Name:WARREN, KIMBERLY RAE (MSN, APRN, AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RAE
Last Name:WARREN
Suffix:
Gender:F
Credentials:MSN, APRN, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 GA HIGHWAY 130 W
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-5555
Mailing Address - Country:US
Mailing Address - Phone:912-245-5491
Mailing Address - Fax:
Practice Address - Street 1:2203 GA HIGHWAY 130 W
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-5555
Practice Address - Country:US
Practice Address - Phone:912-245-5491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN269449363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health