Healthcare Provider Details

I. General information

NPI: 1972326593
Provider Name (Legal Business Name): KIMBERLY ANNE STEPHENS MC, MBG, TP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3286 VINEVILLE AVE STE A
MACON GA
31204-0787
US

IV. Provider business mailing address

3286 VINEVILLE AVE STE A
MACON GA
31204-0787
US

V. Phone/Fax

Practice location:
  • Phone: 478-227-2948
  • Fax:
Mailing address:
  • Phone: 478-227-2948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number1744P3200X
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: