Healthcare Provider Details

I. General information

NPI: 1023624319
Provider Name (Legal Business Name): ANDREA LORA ACQUAVIVA-KIMBROUGH FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 08/02/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 DOCTOR M.L.K. JR PKWY
MORRISTOWN TN
37813
US

IV. Provider business mailing address

1436 CREST VIEW CIR
MORRISTOWN TN
37814-1541
US

V. Phone/Fax

Practice location:
  • Phone: 423-587-1987
  • Fax:
Mailing address:
  • Phone: 423-736-9541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28021
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: