1801368741 NPI number — KIMBERLY JOHNSON GROSS FNP, PMHNP

Table of content: KIMBERLY JOHNSON GROSS FNP, PMHNP (NPI 1801368741)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801368741 NPI number — KIMBERLY JOHNSON GROSS FNP, PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSS
Provider First Name:
KIMBERLY
Provider Middle Name:
JOHNSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP, PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801368741
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7215 S SIWELL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BYRAM
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39272-9776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-373-2204
Provider Business Mailing Address Fax Number:
601-373-4413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
348 CROSSGATES BLVD STE 1500
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANDON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39042-2687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-824-2236
Provider Business Practice Location Address Fax Number:
601-825-2699
Provider Enumeration Date:
12/17/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  875256 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)