Healthcare Provider Details

I. General information

NPI: 1124214101
Provider Name (Legal Business Name): ALTA RUTH EBERT 0000012626
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 03/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 E 11TH ST
CHATTANOOGA TN
37403-3103
US

IV. Provider business mailing address

730 E 11TH ST
CHATTANOOGA TN
37403-3103
US

V. Phone/Fax

Practice location:
  • Phone: 423-265-5708
  • Fax:
Mailing address:
  • Phone: 423-265-5708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0000012626
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: