Healthcare Provider Details

I. General information

NPI: 1376195594
Provider Name (Legal Business Name): KIMBERLY AFTON BOONE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 CONCOURSE AVE STE 142
MEMPHIS TN
38104-4570
US

IV. Provider business mailing address

1350 CONCOURSE AVE STE 142
MEMPHIS TN
38104-4570
US

V. Phone/Fax

Practice location:
  • Phone: 901-272-0003
  • Fax: 907-722-8078
Mailing address:
  • Phone: 901-701-2032
  • Fax: 907-722-8078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3191
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: