Healthcare Provider Details

I. General information

NPI: 1134666191
Provider Name (Legal Business Name): THERESA ANN GROOMES NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PARK BLVD STE 350W
BRISTOL TN
37620-7471
US

IV. Provider business mailing address

PO BOX 4018
JOHNSON CITY TN
37602-4018
US

V. Phone/Fax

Practice location:
  • Phone: 423-282-1480
  • Fax: 423-928-1353
Mailing address:
  • Phone: 423-282-1480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22121
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024188331
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: