Healthcare Provider Details

I. General information

NPI: 1386028488
Provider Name (Legal Business Name): JORDAN L DYER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 08/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7701 CORRYTON RD
CORRYTON TN
37721-2630
US

IV. Provider business mailing address

PO BOX 316
CORRYTON TN
37721-0316
US

V. Phone/Fax

Practice location:
  • Phone: 865-992-3031
  • Fax: 865-992-8103
Mailing address:
  • Phone: 865-992-3031
  • Fax: 865-992-8103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20160
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: