Healthcare Provider Details

I. General information

NPI: 1568706828
Provider Name (Legal Business Name): MAIN STREET FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 N MAIN ST
BULLS GAP TN
37711-4735
US

IV. Provider business mailing address

113 N MAIN ST
BULLS GAP TN
37711-4735
US

V. Phone/Fax

Practice location:
  • Phone: 423-393-4212
  • Fax: 423-393-4257
Mailing address:
  • Phone: 423-393-4212
  • Fax: 423-393-4257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12848
License Number StateTN

VIII. Authorized Official

Name: MICHELLE D CATE
Title or Position: OWNER
Credential: NP
Phone: 423-393-4212