Provider Demographics
NPI:1972326593
Name:STEPHENS, KIMBERLY ANNE (MC, MBG, TP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:MC, MBG, TP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3286 VINEVILLE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-0787
Mailing Address - Country:US
Mailing Address - Phone:478-227-2948
Mailing Address - Fax:
Practice Address - Street 1:3286 VINEVILLE AVE STE A
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-0787
Practice Address - Country:US
Practice Address - Phone:478-227-2948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1744P3200X1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management