Provider Demographics
NPI:1851610356
Name:ROSE, KIMBERLY JEAN (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEAN
Last Name:ROSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1431 CENTERPOINT BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-1984
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:923 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-2768
Practice Address - Country:US
Practice Address - Phone:423-907-1404
Practice Address - Fax:423-907-1160
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN1795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant