Basic Information
| Provider Information | |||||||||
| NPI: | 1871805820 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGENT | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | COGHLAN | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 864 WILSON DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391574512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012066100 | ||||||||
| FaxNumber: | 6012066052 | ||||||||
| Practice Location | |||||||||
| Address1: | 407 S VALLEY ST | ||||||||
| Address2: | |||||||||
| City: | CARTHAGE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390514051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012980333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2010 | ||||||||
| LastUpdateDate: | 12/09/2013 | ||||||||
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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 | 363LF0000X | R870206 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 00150271 | 05 | MS | MEDICAID |