Provider Demographics
NPI:1356113252
Name:KIMBROUGH, PORSHA (PMHNP)
Entity type:Individual
Prefix:
First Name:PORSHA
Middle Name:
Last Name:KIMBROUGH
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2078 NUTHATCH DR
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-5401
Mailing Address - Country:US
Mailing Address - Phone:619-301-5315
Mailing Address - Fax:
Practice Address - Street 1:2160 FOUNTAIN DR STE 100
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-7022
Practice Address - Country:US
Practice Address - Phone:678-344-8268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29352363LP0808X
GARN273706363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health