Healthcare Provider Details

I. General information

NPI: 1376714667
Provider Name (Legal Business Name): KIMBERLY GHOLAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 COLUMBIA AVE STE B
PRENTISS MS
39474-0177
US

IV. Provider business mailing address

PO BOX 177
PRENTISS MS
39474-0177
US

V. Phone/Fax

Practice location:
  • Phone: 601-792-0664
  • Fax: 844-274-1342
Mailing address:
  • Phone: 601-441-3537
  • Fax: 601-792-0664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: