Healthcare Provider Details

I. General information

NPI: 1023204138
Provider Name (Legal Business Name): MRS. SHARON BONITA MERRYMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 REGENCY LN
ELIZABETHTON TN
37643-3062
US

IV. Provider business mailing address

609 REGENCY LN
ELIZABETHTON TN
37643-3062
US

V. Phone/Fax

Practice location:
  • Phone: 423-543-5652
  • Fax: 423-543-5652
Mailing address:
  • Phone: 423-543-5652
  • Fax: 423-543-5652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN0000057012
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: