Healthcare Provider Details

I. General information

NPI: 1093180531
Provider Name (Legal Business Name): KIMBERLY KENNEDY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 JEFFERSON ST
LAUREL MS
39440-4243
US

IV. Provider business mailing address

PO BOX 247
LAUREL MS
39441-0247
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-7522
  • Fax: 601-649-3551
Mailing address:
  • Phone: 601-425-7522
  • Fax: 601-649-3551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberR874680
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number874680
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: