Basic Information
| Provider Information | |||||||||
| NPI: | 1245314590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E 2ND AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 TURNER MCCALL BLVD SW | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301655630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062912745 | ||||||||
| FaxNumber: | 7062916759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 06/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN210799 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.