Provider Demographics
NPI:1144544982
Name:RANDOLPH, KIMBERLY M (APN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3180 PROFESSIONAL PLZ
Mailing Address - Street 2:STE 111
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1534
Mailing Address - Country:US
Mailing Address - Phone:901-854-5455
Mailing Address - Fax:901-861-7736
Practice Address - Street 1:3180 PROFESSIONAL PLZ
Practice Address - Street 2:STE 111
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1534
Practice Address - Country:US
Practice Address - Phone:901-854-5455
Practice Address - Fax:901-861-7736
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7234363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1518380Medicaid
TN103I50964Medicare PIN
TN1518380Medicaid