Healthcare Provider Details

I. General information

NPI: 1275461410
Provider Name (Legal Business Name): KIMBERLY ANN WILKERSON LDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2026
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 HWY 27 N BYP
BREMEN GA
30110-1950
US

IV. Provider business mailing address

486 SALEM CHURCH RD
TALLAPOOSA GA
30176-2348
US

V. Phone/Fax

Practice location:
  • Phone: 770-537-6386
  • Fax: 770-537-6535
Mailing address:
  • Phone: 770-537-6386
  • Fax: 770-537-6535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberLDO002701
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: