1639208333 NPI number — KEMBERLY AMANDA STONE PA-C

Table of content: KEMBERLY AMANDA STONE PA-C (NPI 1639208333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639208333 NPI number — KEMBERLY AMANDA STONE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STONE
Provider First Name:
KEMBERLY
Provider Middle Name:
AMANDA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1639208333
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
453 LAKES BLVD
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
LAKE PARK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31636-6607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-588-2866
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
453 LAKES BLVD SUITE B
Provider Second Line Business Practice Location Address:
LAKE PARK FAMILY CARE CLINIC
Provider Business Practice Location Address City Name:
LAKE PARK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-588-2866
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/06/2007

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: 363A00000X , with the licence number:  05480 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 05480 . This is a "GEORGIA MEDICAL LICENSE NUMBER: 05480 EXPIRATION 01/31/2016" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com