Healthcare Provider Details

I. General information

NPI: 1114405354
Provider Name (Legal Business Name): LACIE GAIL GUDGER NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LACIE GAIL THOMPSON

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3360 HIGHWAY 411 N
ENGLEWOOD TN
37329-5276
US

IV. Provider business mailing address

6350 W ANDREW JOHNSON HWY
TALBOTT TN
37877-8605
US

V. Phone/Fax

Practice location:
  • Phone: 423-887-5131
  • Fax: 423-887-5917
Mailing address:
  • Phone: 800-355-3565
  • Fax: 423-714-2355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN181114
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN24561
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: