Healthcare Provider Details

I. General information

NPI: 1790101558
Provider Name (Legal Business Name): CELESTE Y SORAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2014
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 MEDICAL PARK BLVD
BRISTOL TN
37620-7455
US

IV. Provider business mailing address

105 W STONE DR SUITE 6A
KINGSPORT TN
37660-3365
US

V. Phone/Fax

Practice location:
  • Phone: 423-968-2311
  • Fax: 423-968-2109
Mailing address:
  • Phone: 423-408-7220
  • Fax: 423-408-7405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024171583
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19149
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: