MEDICARE: EAST NASHVILLE PEDIATRICS PLLC

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	261QP2300X	Primary Care Clinic/Center
2	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1801477369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST NASHVILLE PEDIATRICS PLLC

Provider Business Mailing Address
First Line	:	1612 SUMNER AVE
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37206-2536
Country	:	US
Telephone Number	:	917-846-9609
Fax Number	:

Provider Business Practice Location Address
First Line	:	3926 GALLATIN PIKE STE B
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37216-2436
Country	:	US
Telephone Number	:	917-846-9609
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BREANNA LUSTRE
Credential	:	MD
Telephone Number	:	615-882-4900

Provider Enumeration Date	:	04/16/2021
Last Update Date	:	10/01/2021

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