Healthcare Provider Details

I. General information

NPI: 1114922937
Provider Name (Legal Business Name): PHYLLIS C FISHER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. PHYLLIS C DEEL

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 01/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1826 N MAIN AVE
ERWIN TN
37650-8932
US

IV. Provider business mailing address

PO BOX 850
ROGERSVILLE TN
37857-0850
US

V. Phone/Fax

Practice location:
  • Phone: 423-743-6135
  • Fax: 423-743-0035
Mailing address:
  • Phone: 423-743-6135
  • Fax: 423-743-0035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6698
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: