| Doctor Name: | KIMBERLY TANNER FAVA |
| NPI Number: | 1215195631 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | WHCNP, APRN |
| License Number: | R854373 |
| Business Practice Address: | 2000 N State St Clarksdale, MS - 386146100 |
| Business Phone Number: | 6626277361 |
| Business Fax Number: | 6626271158 |
| Mailing Address: | 2000 N State St, CLARKSDALE |
| State: | MS |
| Postal Code: | 386146100 |
| Phone Number: | 6626277361 |
| Fax Number: | 6626271158 |
| NPI Enumeration Date: | 06/02/2008 |
| NPI Last Update Date: | 03/04/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LX0001X |
| License Number: | R854373 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MS |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Obstetrics & Gynecology |
| Taxonomy Definition: | |