Healthcare Provider Details

I. General information

NPI: 1285240010
Provider Name (Legal Business Name): KIMBERLY NICOLE EDWARDS MCLEAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 SUTHERLIN DR STE C1
WARNER ROBINS GA
31088-2266
US

IV. Provider business mailing address

PO BOX 749495
ATLANTA GA
30374-9495
US

V. Phone/Fax

Practice location:
  • Phone: 478-743-7068
  • Fax: 478-741-1354
Mailing address:
  • Phone: 855-963-2100
  • Fax: 813-321-1296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10044
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: