=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306802236
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY LOTT PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 DOCTORS DR STE G
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31533-2211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-384-6186
-----------------------------------------------------
Fax | 912-384-6187
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1377
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31534-1377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-384-1477
-----------------------------------------------------
Fax | 912-384-1470
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 004095
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------