Provider Demographics
NPI:1992874168
Name:TUCKER, KIMBERLY ROCHELLE BROWN (FNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ROCHELLE BROWN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ROCHELLE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:875 W POPLAR AVE STE 23-287
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-2513
Mailing Address - Country:US
Mailing Address - Phone:901-488-5126
Mailing Address - Fax:
Practice Address - Street 1:7601 SOUTHCREST PARKWAY
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671
Practice Address - Country:US
Practice Address - Phone:662-772-2980
Practice Address - Fax:662-772-2960
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15559363L00000X
MSR863928363L00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner