Healthcare Provider Details

I. General information

NPI: 1295646172
Provider Name (Legal Business Name): KIMBERLYN LEE AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5314 MICHAEL CT
GRAND BLANC MI
48439-4326
US

IV. Provider business mailing address

5314 MICHAEL CT
GRAND BLANC MI
48439-4326
US

V. Phone/Fax

Practice location:
  • Phone: 810-845-8756
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704380835
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: