Healthcare Provider Details

I. General information

NPI: 1295751626
Provider Name (Legal Business Name): THE WOUND PRACTITIONER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 N GATEWAY AVE
HARRIMAN TN
37748-8609
US

IV. Provider business mailing address

319 BLUFF RD
KINGSTON TN
37763-7231
US

V. Phone/Fax

Practice location:
  • Phone: 865-882-2442
  • Fax:
Mailing address:
  • Phone: 865-466-0768
  • Fax: 865-717-1113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberAPN0000010924
License Number StateTN

VIII. Authorized Official

Name: ROSELLA SMALLEY
Title or Position: SOLE PROPRIETER
Credential: APN
Phone: 865-466-0768