MEDICARE: KIMBERLY WIGGINS

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	104100000X	Social Worker	MSW009387	GA

General Provider Information

NPI Number	:	1316615065
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY WIGGINS

Provider Business Mailing Address
First Line	:	629 DAWSONVILLE HWY STE 2201
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-2632
Country	:	US
Telephone Number	:	678-701-8477
Fax Number	:	229-516-1395

Provider Business Practice Location Address
First Line	:	629 DAWSONVILLE HWY STE 2201
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-2632
Country	:	US
Telephone Number	:	678-701-8477
Fax Number	:	229-516-1395

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

Provider Enumeration Date	:	08/30/2021
Last Update Date	:	08/30/2021

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