Healthcare Provider Details

I. General information

NPI: 1568570273
Provider Name (Legal Business Name): EAST TENNESSEE STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 09/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 STOUT DRIVE NICKS HALL RM 160
JOHNSON CITY TN
37614-6500
US

IV. Provider business mailing address

365 STOUT DRIVE BOX 70403
JOHNSON CITY TN
37614-1703
US

V. Phone/Fax

Practice location:
  • Phone: 423-439-4225
  • Fax: 423-439-4560
Mailing address:
  • Phone: 423-439-4515
  • Fax: 423-439-5780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BETTY J KING
Title or Position: ACTING CHIEF FINANCIAL OFFICER
Credential:
Phone: 423-439-4414