Provider Demographics
NPI:1659818474
Name:CUSHMAN, KASEY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:CUSHMAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 S B B KING BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-9802
Mailing Address - Country:US
Mailing Address - Phone:901-436-1381
Mailing Address - Fax:
Practice Address - Street 1:3514 MAIN ST
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:CT
Practice Address - Zip Code:06238-1551
Practice Address - Country:US
Practice Address - Phone:860-742-3543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6938363LF0000X
NC5011067363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily