Healthcare Provider Details

I. General information

NPI: 1073663167
Provider Name (Legal Business Name): KIMBERLY DENISE PEGUES FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3869 HIGHWAY 81
LOGANVILLE GA
30052-3918
US

IV. Provider business mailing address

1500 WHEAT GRASS WAY
GRAYSON GA
30017-4138
US

V. Phone/Fax

Practice location:
  • Phone: 678-635-8650
  • Fax:
Mailing address:
  • Phone: 678-362-0570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN127796
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: