Healthcare Provider Details

I. General information

NPI: 1174071369
Provider Name (Legal Business Name): KIMBERLY LEDBETTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 NEAL ST
COOKEVILLE TN
38501-0901
US

IV. Provider business mailing address

2964 HILHAM HWY
HILHAM TN
38568-5610
US

V. Phone/Fax

Practice location:
  • Phone: 931-528-8593
  • Fax:
Mailing address:
  • Phone: 931-397-1303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number71783
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: