Healthcare Provider Details

I. General information

NPI: 1588490239
Provider Name (Legal Business Name): GRACE WELLIVER CPM-TN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 E MADISON AVE
ATHENS TN
37303-3646
US

IV. Provider business mailing address

PO BOX 121
ATHENS TN
37371-0121
US

V. Phone/Fax

Practice location:
  • Phone: 423-252-4555
  • Fax: 423-370-1799
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number170
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: