Basic Information
| Provider Information | |||||||||
| NPI: | 1841280286 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | KIMBERLY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4068 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378024068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652731752 | ||||||||
| FaxNumber: | 8652731755 | ||||||||
| Practice Location | |||||||||
| Address1: | 907 E LAMAR ALEXANDER PKWY | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378045015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659804897 | ||||||||
| FaxNumber: | 8659774796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 05/02/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 6185 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.