Healthcare Provider Details

I. General information

NPI: 1720022395
Provider Name (Legal Business Name): GARY H BALLARD NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 MCBRIEN RD
EAST RIDGE TN
37412-3223
US

IV. Provider business mailing address

992 CLIFT CAVE RD
SODDY DAISY TN
37379-5700
US

V. Phone/Fax

Practice location:
  • Phone: 423-894-3589
  • Fax: 423-892-3378
Mailing address:
  • Phone: 423-332-9218
  • Fax: 423-605-4704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN0000063398
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: