Provider Demographics
NPI:1386279362
Name:WILEY, KIMBERLY LAUREN (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LAUREN
Last Name:WILEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6070 STILLWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-4427
Mailing Address - Country:US
Mailing Address - Phone:678-630-5229
Mailing Address - Fax:
Practice Address - Street 1:3970 DEPUTY BILL CANTRELL MEMORIAL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040
Practice Address - Country:US
Practice Address - Phone:678-513-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA184643363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily