Healthcare Provider Details

I. General information

NPI: 1225951965
Provider Name (Legal Business Name): WILLIAM MADDOX
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6965 CUMBERLAND GAP PKWY
HARROGATE TN
37752-8245
US

IV. Provider business mailing address

469 BIG BLOODY CREEK RD
CAMPTON KY
41301-9592
US

V. Phone/Fax

Practice location:
  • Phone: 423-869-3611
  • Fax:
Mailing address:
  • Phone: 615-681-6125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1154203
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: