Provider Demographics
NPI:1841581261
Name:PRESTON, KIMBERLY W (APN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:W
Last Name:PRESTON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-423-8697
Mailing Address - Fax:731-422-5743
Practice Address - Street 1:87 MURRAY GUARD DR STE B
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3775
Practice Address - Country:US
Practice Address - Phone:731-664-1375
Practice Address - Fax:731-660-8319
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15404363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1523473Medicaid
TNP00938202Medicare PIN
TN1523473Medicaid