Provider Demographics
NPI:1437739034
Name:HALL, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HALL
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 1:6000 POPLAR AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3974
Mailing Address - Country:US
Mailing Address - Phone:662-356-1234
Mailing Address - Fax:901-874-5850
Practice Address - Street 1:6000 POPLAR AVE STE 250
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3974
Practice Address - Country:US
Practice Address - Phone:662-356-1234
Practice Address - Fax:901-874-5850
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNI000000028235253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ064797Medicaid