MEDICARE: MRS. KIMBERLY DENISE PEGUES FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN127796	GA

General Provider Information

NPI Number	:	1073663167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY DENISE PEGUES FNP-C

Provider Business Mailing Address
First Line	:	1500 WHEAT GRASS WAY
Second Line	:
City	:	GRAYSON
State	:	GA
Zip	:	30017-4138
Country	:	US
Telephone Number	:	678-362-0570
Fax Number	:

Provider Business Practice Location Address
First Line	:	3869 HIGHWAY 81
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-3918
Country	:	US
Telephone Number	:	678-635-8650
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	06/15/2020

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