Healthcare Provider Details

I. General information

NPI: 1447362736
Provider Name (Legal Business Name): OTIS BRANDON FORRESTER FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 DUNHILL PL NW
CLEVELAND TN
37311-3885
US

IV. Provider business mailing address

102 DUNHILL PL NW
CLEVELAND TN
37311-3885
US

V. Phone/Fax

Practice location:
  • Phone: 423-339-9581
  • Fax: 423-472-0494
Mailing address:
  • Phone: 423-339-9581
  • Fax: 423-472-0494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number29396
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number29396
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: