Provider Demographics
NPI:1104460328
Name:MABRY-PAROLINE, KIMBERLY L (APRN, FNP-BC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:MABRY-PAROLINE
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:L
Other - Last Name:MABRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, FNP-C
Mailing Address - Street 1:523 S FANNIN AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8204
Mailing Address - Country:US
Mailing Address - Phone:903-535-9041
Mailing Address - Fax:
Practice Address - Street 1:107 WOODBINE PL
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-2912
Practice Address - Country:US
Practice Address - Phone:903-758-2471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143726363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty