Healthcare Provider Details

I. General information

NPI: 1124637905
Provider Name (Legal Business Name): CAROLINE DERRICK STEPHENS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 01/22/2026
Certification Date: 01/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 KNOB CREEK RD STE 704
JOHNSON CITY TN
37604-2977
US

IV. Provider business mailing address

1568 RACCOON LN
PINEY FLATS TN
37686-2934
US

V. Phone/Fax

Practice location:
  • Phone: 423-929-9101
  • Fax:
Mailing address:
  • Phone: 615-477-0493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: