Healthcare Provider Details

I. General information

NPI: 1972069722
Provider Name (Legal Business Name): COURTNEY CARROLL FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 FOREST DR STE 5
GRAY TN
37615-8423
US

IV. Provider business mailing address

1326 PAPERMILL POINTE WAY
KNOXVILLE TN
37909-1903
US

V. Phone/Fax

Practice location:
  • Phone: 423-794-3142
  • Fax:
Mailing address:
  • Phone: 865-673-5000
  • Fax: 865-330-6323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number25120
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: