Healthcare Provider Details

I. General information

NPI: 1013387349
Provider Name (Legal Business Name): MARY BETH BYRD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2015
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 GAY ST
ERWIN TN
37650-1228
US

IV. Provider business mailing address

931 PRINCE AVE
ERWIN TN
37650-1445
US

V. Phone/Fax

Practice location:
  • Phone: 423-388-4525
  • Fax: 423-388-4524
Mailing address:
  • Phone: 423-335-3077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number175773
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20178
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: