Provider Demographics
NPI:1215195631
Name:FAVA, KIMBERLY TANNER (WHCNP, APRN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:TANNER
Last Name:FAVA
Suffix:
Gender:F
Credentials:WHCNP, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6100
Mailing Address - Country:US
Mailing Address - Phone:662-627-7361
Mailing Address - Fax:662-627-1158
Practice Address - Street 1:2000 N STATE ST
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6100
Practice Address - Country:US
Practice Address - Phone:662-627-7361
Practice Address - Fax:662-627-1158
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR854373363LX0001X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS3459830Medicaid
MS3459830Medicaid