MEDICARE: KIMBLEY BENNETT FNP-BC

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	363L00000X	Nurse Practitioner	RN183629	GA

General Provider Information

NPI Number	:	1578080784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBLEY BENNETT FNP-BC

Provider Business Mailing Address
First Line	:	1942 NORTH AVE
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31901-1525
Country	:	US
Telephone Number	:	706-596-1245
Fax Number	:	706-576-4245

Provider Business Practice Location Address
First Line	:	1942 NORTH AVE
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31901-1525
Country	:	US
Telephone Number	:	706-596-1245
Fax Number	:	706-576-4245

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

Provider Enumeration Date	:	08/28/2017
Last Update Date	:	07/21/2022

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