Provider Demographics
NPI:1366704488
Name:TATUM, KIMBERLY ANNE (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:TATUM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 JUNIPER CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-6819
Mailing Address - Country:US
Mailing Address - Phone:330-416-3833
Mailing Address - Fax:
Practice Address - Street 1:4125 LAWNDALE DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-1885
Practice Address - Country:US
Practice Address - Phone:336-543-0786
Practice Address - Fax:336-234-5411
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005656363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7006143Medicaid
NCNC7468AMedicare PIN