Provider Demographics
NPI:1861967564
Name:HOLLIS, KIMBERLY (FNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 FAIR RD STE 105A
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-6118
Mailing Address - Country:US
Mailing Address - Phone:276-591-0818
Mailing Address - Fax:
Practice Address - Street 1:1525 FAIR RD STE 105A
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-6118
Practice Address - Country:US
Practice Address - Phone:276-591-0818
Practice Address - Fax:912-259-9509
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN281463363LF0000X
FLAPRN11013778363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110958000Medicaid