Basic Information
| Provider Information | |||||||||
| NPI: | 1730411059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLK | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHANNON | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1000 DEPT 941 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381010941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017260843 | ||||||||
| FaxNumber: | 9012782695 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 EASTMORELAND AVE | ||||||||
| Address2: | STE 550 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381047507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017260843 | ||||||||
| FaxNumber: | 9012782695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2010 | ||||||||
| LastUpdateDate: | 08/21/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 14737 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1518648 | 05 | TN | MEDICAID | P00873632 | 01 | TN | RAILROAD MEDICARE | OTHER |