MEDICARE: SARA JO WELLS APRN

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	163W00000X	Registered Nurse	238476	TN
2	363LF0000X	Family Nurse Practitioner	36543	TN

General Provider Information

NPI Number	:	1366273104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA JO WELLS APRN

Provider Business Mailing Address
First Line	:	16850 STATE HIGHWAY 58 S
Second Line	:
City	:	DECATUR
State	:	TN
Zip	:	37322-5259
Country	:	US
Telephone Number	:	423-334-2300
Fax Number	:	423-205-8410

Provider Business Practice Location Address
First Line	:	16850 STATE HIGHWAY 58 S
Second Line	:
City	:	DECATUR
State	:	TN
Zip	:	37322-5259
Country	:	US
Telephone Number	:	423-334-2300
Fax Number	:

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

Provider Enumeration Date	:	08/13/2024
Last Update Date	:	11/15/2024

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