Basic Information
| Provider Information | |||||||||
| NPI: | 1750725636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLINS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | RENAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MUPRHY | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376620009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238572066 | ||||||||
| FaxNumber: | 4238572070 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 ADVANCED TECHNOLOGY DRIVE | ||||||||
| Address2: | |||||||||
| City: | DUFFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2764312648 | ||||||||
| FaxNumber: | 2764312082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2013 | ||||||||
| LastUpdateDate: | 10/19/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0017140919 | VA | N | Nursing Service Providers | Registered Nurse | 164W00000X | 0001201805 | VA | N | Nursing Service Providers | Licensed Practical Nurse | 363LF0000X | 0024170685 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | Q004515 | 05 | TN | MEDICAID |