Provider Demographics
NPI:1023624319
Name:ACQUAVIVA-KIMBROUGH, ANDREA LORA (FNP-BC)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:LORA
Last Name:ACQUAVIVA-KIMBROUGH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 CREST VIEW CIR
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-1541
Mailing Address - Country:US
Mailing Address - Phone:423-736-9541
Mailing Address - Fax:
Practice Address - Street 1:220 DOCTOR M.L.K. JR PKWY
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37813
Practice Address - Country:US
Practice Address - Phone:423-587-1987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28021363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily