Provider Demographics
NPI:1124334511
Name:NELSON, KIMBERLY PIERCE (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:PIERCE
Last Name:NELSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:DAWN
Other - Last Name:PIERCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 23457
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3457
Mailing Address - Country:US
Mailing Address - Phone:601-200-6836
Mailing Address - Fax:601-200-0128
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-200-6836
Practice Address - Fax:601-200-0128
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865368363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS468179YKHVOtherMEDICARE ST DOM
MS07175291Medicaid