Healthcare Provider Details

I. General information

NPI: 1578169090
Provider Name (Legal Business Name): DEA WELLS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

273 HIGHWAY 11 E
BULLS GAP TN
37711-3433
US

IV. Provider business mailing address

273 HIGHWAY 11 E
BULLS GAP TN
37711-3433
US

V. Phone/Fax

Practice location:
  • Phone: 423-393-4146
  • Fax: 423-393-4377
Mailing address:
  • Phone: 423-956-5485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26209
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: