Provider Demographics
NPI:1215207451
Name:BACON, KIMBERLY S (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:BACON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 24
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6089
Mailing Address - Country:US
Mailing Address - Phone:423-431-1810
Mailing Address - Fax:423-431-1811
Practice Address - Street 1:408 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 24
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6089
Practice Address - Country:US
Practice Address - Phone:423-431-1810
Practice Address - Fax:423-431-1811
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15209363LF0000X
TNAPN0000015209363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1215207451Medicaid
TN1527812Medicaid
VA7100195690Medicaid
TNP01200424OtherRAILROAD MEDICARE PIN
KY7100195690Medicaid
TN103I506419Medicare PIN