Healthcare Provider Details

I. General information

NPI: 1881353712
Provider Name (Legal Business Name): MRS. LYDIA GABRIELLA ROBINSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYDIA GABRIELLA OTTEM

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N STATE OF FRANKLIN RD RM 2746
JOHNSON CITY TN
37604-6035
US

IV. Provider business mailing address

1021 W OAKLAND AVE STE 310
JOHNSON CITY TN
37604-2192
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-2727
  • Fax: 423-431-2814
Mailing address:
  • Phone: 423-952-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number31159
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number31159
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number0000231637
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: