Healthcare Provider Details

I. General information

NPI: 1619334562
Provider Name (Legal Business Name): KIMBERLEY RENEE COLE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2016
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 PROFESSIONAL DR. SUITE 150
LAWRENCEVILLE GA
30046
US

IV. Provider business mailing address

575 PROFESSIONAL DRIVE SUITE 150
LAWRENCEVILLE GA
30046
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-5200
  • Fax: 678-312-5289
Mailing address:
  • Phone: 770-616-2760
  • Fax: 678-312-5289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN139658
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberRN139658
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN139658
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN139658
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: