Healthcare Provider Details

I. General information

NPI: 1023307840
Provider Name (Legal Business Name): KIMBERLY DIANE APOSTOLIDIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY BOOTH NP

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 N STATE ST STE 203
JACKSON MS
39202-1658
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 103
MEMPHIS TN
38120-9446
US

V. Phone/Fax

Practice location:
  • Phone: 601-355-1234
  • Fax: 601-718-2778
Mailing address:
  • Phone:
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR874910
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: