Basic Information
Provider Information | |||||||||
NPI: | 1235107004 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLIAMS | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HILL | ||||||||
OtherFirstName: | KIMBERLY | ||||||||
OtherMiddleName: | MAE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CNM | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4502 OLD PASS RD | ||||||||
Address2: |   | ||||||||
City: | GULFPORT | ||||||||
State: | MS | ||||||||
PostalCode: | 395012585 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2288639977 | ||||||||
FaxNumber: | 2288639912 | ||||||||
Practice Location | |||||||||
Address1: | 4502 OLD PASS RD | ||||||||
Address2: |   | ||||||||
City: | GULFPORT | ||||||||
State: | MS | ||||||||
PostalCode: | 395012585 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2288639977 | ||||||||
FaxNumber: | 2288639912 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2006 | ||||||||
LastUpdateDate: | 08/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | R876822 | MS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | 07782252 | 05 | MS |   | MEDICAID | 001174200 | 05 | FL |   | MEDICAID |