Provider Demographics
NPI:1922469063
Name:TYNER, KIMBERLY ANN (NP-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:TYNER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ECHOLS
Other - Last Name:TYNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1824 AUGUST BND
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6825
Mailing Address - Country:US
Mailing Address - Phone:601-941-3863
Mailing Address - Fax:
Practice Address - Street 1:514 E WOODROW WILSON AVE STE F
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4538
Practice Address - Country:US
Practice Address - Phone:601-982-3132
Practice Address - Fax:601-982-3136
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR824497363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily