Provider Demographics
NPI:1407981491
Name:TENNYSON, KIMBERLY GAYE (MED)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:GAYE
Last Name:TENNYSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX 792
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-9598
Mailing Address - Country:US
Mailing Address - Phone:618-897-2430
Mailing Address - Fax:618-897-2441
Practice Address - Street 1:RR 3 BOX 792
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-9598
Practice Address - Country:US
Practice Address - Phone:618-897-2430
Practice Address - Fax:618-897-2441
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist