Basic Information
Provider Information
NPI: 1033558861
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HARRIS
FirstName: KIMBERLY
MiddleName: A
NamePrefix: MRS.
NameSuffix:  
Credential: CPNP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4000 SHAKERAG HL
Address2: STE 201
City: PEACHTREE CITY
State: GA
PostalCode: 302694047
CountryCode: US
TelephoneNumber: 7706644430
FaxNumber: 7706647836
Practice Location
Address1: 1100 NORTHMEADOW PARKWAY
Address2: SUITE 108
City: ROSWELL
State: GA
PostalCode: 300763871
CountryCode: US
TelephoneNumber: 7706644430
FaxNumber: 7706647836
Other Information
ProviderEnumerationDate: 06/14/2013
LastUpdateDate: 02/22/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LP0200XRN171399GAY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics

No ID Information.


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