MEDICARE: MRS. KEATON LEIGH MIMS M.S.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	APN.18027RX	SC

General Provider Information

NPI Number	:	1619228251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KEATON LEIGH MIMS M.S.N.

Provider Business Mailing Address
First Line	:	PO BOX 602108
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-2108
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1952 LONG GROVE DR
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-7579
Country	:	US
Telephone Number	:	843-971-2992
Fax Number	:	843-971-2998

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2012
Last Update Date	:	02/16/2025

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