MEDICARE: KIYO PHENIQUE HOLMES FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R872814	MS

General Provider Information

NPI Number	:	1770864613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIYO PHENIQUE HOLMES FNP-C

Provider Business Mailing Address
First Line	:	30 BURTON HILLS BLVD
Second Line	:	STE 175
City	:	NASHVILLE
State	:	TN
Zip	:	37215-6403
Country	:	US
Telephone Number	:	615-988-2014
Fax Number	:	615-208-1303

Provider Business Practice Location Address
First Line	:	2363 HIGHWAY 1 S
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38701-8337
Country	:	US
Telephone Number	:	662-334-1253
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2011
Last Update Date	:	10/24/2019

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