Provider Demographics
NPI:1427241421
Name:MATHIS, KIMBERLY D (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:MATHIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:D
Other - Last Name:WOODARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1600 MCARTHUR STREET
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355
Mailing Address - Country:US
Mailing Address - Phone:931-723-7950
Mailing Address - Fax:931-723-7815
Practice Address - Street 1:1600 MCARTHUR STREET
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355
Practice Address - Country:US
Practice Address - Phone:931-723-7950
Practice Address - Fax:931-723-7815
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000005806363L00000X
TN5806363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1516755Medicaid