Healthcare Provider Details

I. General information

NPI: 1740191477
Provider Name (Legal Business Name): KIMBERLY DENISE RAYBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 HIGHWAY 12 W
KOSCIUSKO MS
39090-3208
US

IV. Provider business mailing address

901 KERR ADAMS MILLS RD
LOUISVILLE MS
39339-8134
US

V. Phone/Fax

Practice location:
  • Phone: 662-290-3333
  • Fax:
Mailing address:
  • Phone: 850-860-8655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number890687
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: