Provider Demographics
NPI:1366533986
Name:LATTIMORE, KIM DENISE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:DENISE
Last Name:LATTIMORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:KIM
Other - Middle Name:DENISE
Other - Last Name:LATTIMORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:7000 FELDSPAR CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2212
Mailing Address - Country:US
Mailing Address - Phone:706-507-1185
Mailing Address - Fax:
Practice Address - Street 1:7950 MARTIN LOOP
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-5647
Practice Address - Country:US
Practice Address - Phone:706-573-9363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4741363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant