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General NPI Number Information
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NPI Number | 1871105320
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Entity Type | Individual
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Provider Name | KIWANA N DERRICK RN, AGNP-C
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Gender | Female
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Dates
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Enumeration Date | 08/17/2020
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Last Update Date | 05/04/2026
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Provider Practice Location Address
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Address Line | 835 UNION ST
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City | SHELBYVILLE
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State | TN
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Zip | 37160-2607
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Country | US
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Telephone | 931-680-2300
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2182
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City | LEWISBURG
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State | TN
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Zip | 37091-1182
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Country | US
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Telephone | 931-652-2521
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Fax |
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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 | APN0000028011
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 163WG0600X
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Taxonomy Name | Gerontology Registered Nurse
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License Number | 196202
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License Number State | TN
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