Basic Information
| Provider Information | |||||||||
| NPI: | 1760617005 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINKADE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4975 LACROSS RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294066531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437379467 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2067 CHARLIE HALL BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294145834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435732535 | ||||||||
| FaxNumber: | 8435732534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2009 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0001240478 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 25520 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1760617005 | 05 | IA | MEDICAID | NP7962 | 05 | SC | MEDICAID | 175150023 | 01 | MEDICARE | OTHER |