Provider Demographics
NPI:1518479542
Name:TATUM, KIMBERLY MODENA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MODENA
Last Name:TATUM
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4002 S LOOP 256 STE A
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-8492
Mailing Address - Country:US
Mailing Address - Phone:903-731-5030
Mailing Address - Fax:903-731-5037
Practice Address - Street 1:4002 S LOOP 256 STE A
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-8492
Practice Address - Country:US
Practice Address - Phone:903-731-5030
Practice Address - Fax:903-731-5037
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-31
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136159363LF0000X, 363L00000X, 363LF0000X
FL9471546363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner