Basic Information
Provider Information | |||||||||
NPI: | 1164744090 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NORWOOD | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: | KAYE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | THARPE | ||||||||
OtherFirstName: | KIMBERLY | ||||||||
OtherMiddleName: | KAY | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5683 S REX RD STE A | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381193821 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9013500678 | ||||||||
FaxNumber: | 9013500677 | ||||||||
Practice Location | |||||||||
Address1: | 1720 E REELFOOT AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | UNION CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 382616049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7315070272 | ||||||||
FaxNumber: | 7315070273 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/19/2010 | ||||||||
LastUpdateDate: | 10/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN14751 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 0905 | 01 | TN | GROUP (PTAN ) | OTHER | 1519877 | 05 | TN |   | MEDICAID | 103I502866 | 01 | TN | MEDICARE (PTAN) | OTHER |