Basic Information
| Provider Information | |||||||||
| NPI: | 1952993883 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLOUGHBY | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | JODI ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 EMPORIA LOOP | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302536842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072180916 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 80 JESSE HILL JR DR SE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303033031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046161000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2021 | ||||||||
| LastUpdateDate: | 02/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 267074 | GA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.