Provider Demographics
NPI:1407406119
Name:MCMAHAN, KIMBERLY MARIE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:MCMAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 EAGLE BEND RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-3825
Mailing Address - Country:US
Mailing Address - Phone:865-208-5760
Mailing Address - Fax:865-264-5279
Practice Address - Street 1:620 EAGLE BEND RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716-3825
Practice Address - Country:US
Practice Address - Phone:865-208-5760
Practice Address - Fax:865-264-5279
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-14
Last Update Date:2019-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN0000061259164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse