=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235866898
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIWANNA NISHAE CLARK FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2022
-----------------------------------------------------
Last Update Date | 08/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 426 21ST AVE S # 7608
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37203-2424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-321-2590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3920 PUCKETT CREEK XING APT 104
-----------------------------------------------------
City | MURFREESBORO
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37128-4251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-563-0766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 29323
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------