Provider Demographics
NPI:1811918675
Name:NIELSEN, KIMBERLY ANNETTE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNETTE
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:
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 3889
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3889
Mailing Address - Country:US
Mailing Address - Phone:423-794-2457
Mailing Address - Fax:423-283-9480
Practice Address - Street 1:314 ROGOSIN DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2904
Practice Address - Country:US
Practice Address - Phone:423-433-6630
Practice Address - Fax:423-232-8574
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN-7262363L00000X
TN7262363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3348345Medicaid