=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194911453
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY GWEN METTETAL C.F.N.P. CPMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2007
-----------------------------------------------------
Last Update Date | 07/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8626 AIRWAYS BLVD
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38671-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-772-5937
-----------------------------------------------------
Fax | 662-772-5940
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8626 AIRWAYS BLVD
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38671-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-772-5937
-----------------------------------------------------
Fax | 662-772-5940
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | R850409
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 2018026553
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | AP60842248
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 8391-33
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 2018
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 5816
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | AP136974
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | R850409
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------