Provider Demographics
NPI:1871805820
Name:AGENT, KIMBERLY COGHLAN (FNP-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:COGHLAN
Last Name:AGENT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:864 WILSON DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4512
Mailing Address - Country:US
Mailing Address - Phone:601-206-6100
Mailing Address - Fax:601-206-6052
Practice Address - Street 1:407 S VALLEY ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MS
Practice Address - Zip Code:39051-4051
Practice Address - Country:US
Practice Address - Phone:601-298-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR870206363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00150271Medicaid
MS302642YKJ2Medicare PIN