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General NPI Number Information
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NPI Number | 1679740708
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Entity Type | Individual
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Provider Name | FELICIA DESHA KIMBROUGH FNP BC
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Gender | Female
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Dates
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Enumeration Date | 05/08/2008
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Last Update Date | 08/16/2022
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Provider Practice Location Address
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Address Line | 1301 E WALNUT ST RM J120
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City | CARBONDALE
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State | IL
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Zip | 62901-5004
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Country | US
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Telephone | 618-519-9200
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Fax | 618-457-8931
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Provider Business Mailing Address
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Address Line | 109 CALIFORNIA ST
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City | CARTERVILLE
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State | IL
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Zip | 62918-1923
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Country | US
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Telephone | 618-985-8221
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Fax | 618-985-6860
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 209007991
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License Number State | IL
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