Basic Information
| Provider Information | |||||||||
| NPI: | 1255656070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PLOUSSAS | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 955 RIBAUT RD | ||||||||
| Address2: | |||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435227843 | ||||||||
| FaxNumber: | 8435225945 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 OKATIE CENTER BLVD N STE 310 | ||||||||
| Address2: | |||||||||
| City: | OKATIE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299093782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437068690 | ||||||||
| FaxNumber: | 8442959802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2010 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4230 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | SCB8689125 | 01 | MEDICARE PTAN | OTHER | P01510934 | 01 | SC | RAILROAD MEDICARE | OTHER | NP1618 | 05 | SC | MEDICAID |