Healthcare Provider Details

I. General information

NPI: 1962861310
Provider Name (Legal Business Name): ATOKA IDAVILLE FAMILY HEALTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2016
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5847 ATOKA IDAVILLE RD
BRIGHTON TN
38011-7066
US

IV. Provider business mailing address

5847 ATOKA IDAVILLE RD
BRIGHTON TN
38011-7066
US

V. Phone/Fax

Practice location:
  • Phone: 901-304-8709
  • Fax:
Mailing address:
  • Phone: 901-837-0701
  • Fax: 901-837-0703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number13123
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2007009643
License Number StateTN

VIII. Authorized Official

Name: ROBYN YVETTE VANDERFORD
Title or Position: OWNER/PROVIDER
Credential: FNP
Phone: 901-837-0701