Provider Demographics
NPI:1134220742
Name:SIMNICHT, KIMBERLY T (CFNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:T
Last Name:SIMNICHT
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3688 VETERANS MEMORIAL DR
Mailing Address - Street 2:STE 200
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-8246
Mailing Address - Country:US
Mailing Address - Phone:601-554-7400
Mailing Address - Fax:601-554-7499
Practice Address - Street 1:3688 VETERANS MEMORIAL DR
Practice Address - Street 2:STE 200
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-8246
Practice Address - Country:US
Practice Address - Phone:601-554-7400
Practice Address - Fax:601-554-7499
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR785277174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116081Medicaid
MS500001066Medicare ID - Type Unspecified
MS00116081Medicaid