Provider Demographics
NPI:1194911453
Name:METTETAL, KIMBERLY GWEN (CFNP CPMHNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:GWEN
Last Name:METTETAL
Suffix:
Gender:F
Credentials:CFNP CPMHNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:G
Other - Last Name:METTETAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:8626 AIRWAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-2603
Mailing Address - Country:US
Mailing Address - Phone:662-772-5937
Mailing Address - Fax:662-772-5940
Practice Address - Street 1:8626 AIRWAYS BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-2603
Practice Address - Country:US
Practice Address - Phone:662-772-5937
Practice Address - Fax:662-772-5940
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR850409363LF0000X, 363LP0808X
MO2018026553363LP0808X
WAAP60842248363LP0808X
WI8391-33363LP0808X
OR2018363LP0808X
MN5816363LP0808X
TXAP136974363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06787540Medicaid
TX382605901Medicaid
MS500001510Medicare PIN