Provider Demographics
NPI:1437242724
Name:ROSS, KYMBERLY RAVEN (CFNP)
Entity Type:Individual
Prefix:MS
First Name:KYMBERLY
Middle Name:RAVEN
Last Name:ROSS
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:KYMBERLY
Other - Middle Name:RAVEN
Other - Last Name:VAN EVERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 JACKSON AVE W
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-2154
Mailing Address - Country:US
Mailing Address - Phone:662-234-6464
Mailing Address - Fax:662-234-6475
Practice Address - Street 1:301 JACKSON AVE W
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-2154
Practice Address - Country:US
Practice Address - Phone:662-234-6464
Practice Address - Fax:662-234-6475
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1116194163W00000X
TNAPN0000010481363LP0808X
MSR878897363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06759284Medicaid
MS302I504575Medicare PIN