Healthcare Provider Details

I. General information

NPI: 1508506536
Provider Name (Legal Business Name): KIMBERLY RUSSOM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 W REELFOOT AVE
UNION CITY TN
38261-5569
US

IV. Provider business mailing address

1705 W REELFOOT AVE
UNION CITY TN
38261-5569
US

V. Phone/Fax

Practice location:
  • Phone: 731-599-1102
  • Fax: 731-599-1107
Mailing address:
  • Phone: 731-599-1102
  • Fax: 731-599-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number31286
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: