Provider Demographics
NPI:1437785482
Name:TUPPER, KIMBERLY JORDAN
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JORDAN
Last Name:TUPPER
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 1:5910 WINDING RIVER WAY APT 204
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2917
Mailing Address - Country:US
Mailing Address - Phone:901-921-1771
Mailing Address - Fax:
Practice Address - Street 1:2851 STAGE CENTER DR
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-4679
Practice Address - Country:US
Practice Address - Phone:901-388-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-20
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4214363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant