Provider Demographics
NPI:1134455850
Name:CAROTHERS, NEKAYEH PENNINGTON (FNP)
Entity type:Individual
Prefix:MRS
First Name:NEKAYEH
Middle Name:PENNINGTON
Last Name:CAROTHERS
Suffix:
Gender:F
Credentials:FNP
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 1:616 W FOREST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3902
Practice Address - Country:US
Practice Address - Phone:731-422-0408
Practice Address - Fax:731-422-0486
Is Sole Proprietor?:No
Enumeration Date:2009-10-30
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN13822363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1517020Medicaid
TN103I50005Medicare PIN
TN1517020Medicaid