Provider Demographics
NPI:1043318991
Name:FANNIN - TRISLER, KIMBERLY R (APRN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:R
Last Name:FANNIN - TRISLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1154 LOGAN SEWELL DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-3342
Mailing Address - Country:US
Mailing Address - Phone:318-336-8166
Mailing Address - Fax:318-336-8169
Practice Address - Street 1:2106 LOOP RD # C
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-3344
Practice Address - Country:US
Practice Address - Phone:318-435-4571
Practice Address - Fax:318-435-3842
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA085994363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1447498Medicaid