Healthcare Provider Details

I. General information

NPI: 1215195631
Provider Name (Legal Business Name): KIMBERLY TANNER FAVA WHCNP, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 MEDICAL PARK DR
OXFORD MS
38655-5326
US

IV. Provider business mailing address

8110 N BROTHER BLVD STE 200
BARTLETT TN
38133-2760
US

V. Phone/Fax

Practice location:
  • Phone: 662-236-5717
  • Fax: 662-234-4016
Mailing address:
  • Phone: 901-255-5221
  • Fax: 901-373-4511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number854373
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number854373
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: