Provider Demographics
NPI:1750725636
Name:MULLINS, KIMBERLY RENAE (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RENAE
Last Name:MULLINS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:MUPRHY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:121 ADVANCED TECHNOLOGY DRIVE
Practice Address - Street 2:
Practice Address - City:DUFFIELD
Practice Address - State:VA
Practice Address - Zip Code:24244
Practice Address - Country:US
Practice Address - Phone:276-431-2648
Practice Address - Fax:276-431-2082
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0017140919163W00000X
VA0001201805164W00000X
VA0024170685363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ004515Medicaid
VAVVA496AMedicare PIN