Healthcare Provider Details

I. General information

NPI: 1104148626
Provider Name (Legal Business Name): MATTHEW VERNON GENT FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2010
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 N CHARLES G SEIVERS BLVD SUITE 101
CLINTON TN
37716-3944
US

IV. Provider business mailing address

1923 SULPHUR SPRINGS RD
MORRISTOWN TN
37813-5654
US

V. Phone/Fax

Practice location:
  • Phone: 865-934-6150
  • Fax: 865-342-0150
Mailing address:
  • Phone: 423-317-9344
  • Fax: 423-714-2355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN158503
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN14812
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: