Provider Demographics
NPI:1730411059
Name:POLK, KIMBERLY DAWN (APN)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:POLK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:DAWN
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000 DEPT 941
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38101-0941
Mailing Address - Country:US
Mailing Address - Phone:901-726-0843
Mailing Address - Fax:901-278-2695
Practice Address - Street 1:1325 EASTMORELAND AVE
Practice Address - Street 2:STE 550
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-7507
Practice Address - Country:US
Practice Address - Phone:901-726-0843
Practice Address - Fax:901-278-2695
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14737363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1518648Medicaid
TNP00873632OtherRAILROAD MEDICARE
TN1518648Medicaid