Provider Demographics
NPI:1477036234
Name:NELSON, KIMBERLY PAIGE (LPN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:PAIGE
Last Name:NELSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:PHILLIPS
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:218 INDIAN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-3018
Mailing Address - Country:US
Mailing Address - Phone:423-494-6300
Mailing Address - Fax:423-377-1110
Practice Address - Street 1:218 INDIAN CREEK RD
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TN
Practice Address - Zip Code:37757-3018
Practice Address - Country:US
Practice Address - Phone:423-494-6300
Practice Address - Fax:423-377-1110
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN0000064207164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse