Basic Information
| Provider Information | |||||||||
| NPI: | 1558819052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WINTERS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2030 POWERS FERRY RD SE STE 120 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303395016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788012329 | ||||||||
| FaxNumber: | 8442492637 | ||||||||
| Practice Location | |||||||||
| Address1: | 304 JACOBS HWY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293257279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648332550 | ||||||||
| FaxNumber: | 8649389240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2016 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 20364 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 20364 | 01 | SC | STATE LICENSE NUMBER | OTHER |