Provider Demographics
NPI:1144558404
Name:LANIER, KIMBERLY TYRA (APRN BC CNS/PMH)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:TYRA
Last Name:LANIER
Suffix:
Gender:F
Credentials:APRN BC CNS/PMH
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:ANNE
Other - Last Name:TYRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:5965 PARKWAY NORTH BLVD.
Mailing Address - Street 2:SUITE C
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040
Mailing Address - Country:US
Mailing Address - Phone:770-475-8014
Mailing Address - Fax:770-886-0404
Practice Address - Street 1:11755 POINTE PL STE A1
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4657
Practice Address - Country:US
Practice Address - Phone:770-653-5182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-25
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN119081364SP0809X
GARN119081CNS/PMH364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist