Healthcare Provider Details

I. General information

NPI: 1316775323
Provider Name (Legal Business Name): HIDDEN PATHS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7516 ENTERPRISE AVE # 1
GERMANTOWN TN
38138-3802
US

IV. Provider business mailing address

PO BOX 269
ELLENDALE TN
38029-0269
US

V. Phone/Fax

Practice location:
  • Phone: 901-757-2249
  • Fax:
Mailing address:
  • Phone: 901-216-4354
  • Fax: 888-858-1577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY BANHAM
Title or Position: OWNER
Credential: DNP, APRN, FNP-C
Phone: 901-216-4354