Healthcare Provider Details

I. General information

NPI: 1164342663
Provider Name (Legal Business Name): HEATHER MARIE WINE MSN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 WINE RD
GRAY TN
37615-2485
US

IV. Provider business mailing address

136 WINE RD
GRAY TN
37615-2485
US

V. Phone/Fax

Practice location:
  • Phone: 423-213-2198
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number42485
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: