Provider Demographics
NPI:1609853381
Name:PROCTOR, KIMBERLY E (RN/NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:E
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:RN/NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 N LAUDERDALE ST.
Mailing Address - Street 2:MS 133
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-2794
Mailing Address - Country:US
Mailing Address - Phone:901-495-3006
Mailing Address - Fax:901-495-3842
Practice Address - Street 1:332 N LAUDERDALE ST.
Practice Address - Street 2:MS 133
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-2794
Practice Address - Country:US
Practice Address - Phone:901-495-3006
Practice Address - Fax:901-495-3842
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN97240363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440513Medicaid