Provider Demographics
NPI:1699170019
Name:VANN, KIMBERLY NICOLE (FNP-BC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:VANN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:NICOLE
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:1669 SHELBY OAKS DR N STE 106
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-7441
Mailing Address - Country:US
Mailing Address - Phone:901-382-9292
Mailing Address - Fax:901-384-5696
Practice Address - Street 1:2946 COVINGTON PIKE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-6007
Practice Address - Country:US
Practice Address - Phone:901-382-9292
Practice Address - Fax:901-384-5696
Is Sole Proprietor?:No
Enumeration Date:2014-10-28
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19303363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ009906Medicaid
TN12755888899OtherMD NPI NUMBER