Basic Information
| Provider Information | |||||||||
| NPI: | 1619099918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HATCHER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FERRY, WRAGG | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | DENISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 8824 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319088824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063203770 | ||||||||
| FaxNumber: | 7063203772 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 16TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319011665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063203770 | ||||||||
| FaxNumber: | 7063203772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 08/02/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | RN154558 | GA | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | RN154558 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 003140075B | 05 | GA | MEDICAID | NCO-000003 | 01 | GA | NURSE PRACTITIONER | OTHER | 2013005222 | 01 | GA | PMHCNS-BC | OTHER | 164957 | 05 | AL | MEDICAID | RN154558 | 01 | GA | RN LICENSE | OTHER |