Provider Demographics
NPI:1942642020
Name:WIGGINS, KIM MATTHEWS
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MATTHEWS
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:WIGGINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SLP
Mailing Address - Street 1:2584 FAXON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-2238
Mailing Address - Country:US
Mailing Address - Phone:901-378-3293
Mailing Address - Fax:901-343-9311
Practice Address - Street 1:2584 FAXON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-2238
Practice Address - Country:US
Practice Address - Phone:901-378-3293
Practice Address - Fax:901-343-9311
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN332235Z00000X
TN7238226235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ071980Medicaid