Provider Demographics
NPI:1730835190
Name:JIMMERSON, KELTIN (CRNP)
Entity type:Individual
Prefix:
First Name:KELTIN
Middle Name:
Last Name:JIMMERSON
Suffix:
Gender:
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 JONES RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:AL
Mailing Address - Zip Code:36352-8072
Mailing Address - Country:US
Mailing Address - Phone:334-796-3206
Mailing Address - Fax:
Practice Address - Street 1:104 MEDICAL DR # 104
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-6902
Practice Address - Country:US
Practice Address - Phone:334-671-9447
Practice Address - Fax:334-836-0059
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367A00000X
AL1-162676363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife