Provider Demographics
NPI:1144580820
Name:MASENGILL, KIMBERLY LYNN (FNP-BC, CNM)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:MASENGILL
Suffix:
Gender:F
Credentials:FNP-BC, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:TN
Mailing Address - Zip Code:37185-1512
Mailing Address - Country:US
Mailing Address - Phone:615-299-7378
Mailing Address - Fax:615-299-7399
Practice Address - Street 1:301 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:TN
Practice Address - Zip Code:37185-1512
Practice Address - Country:US
Practice Address - Phone:615-299-7378
Practice Address - Fax:615-299-7399
Is Sole Proprietor?:No
Enumeration Date:2012-05-29
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15969363LF0000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10350I8797Medicare PIN