Healthcare Provider Details

I. General information

NPI: 1174432991
Provider Name (Legal Business Name): SAVANNAH R BOLES RT(R)(MR)RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAVANNAH CLARK RT(R)(MR)RN

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 N STATE OF FRANKLIN RD
JOHNSON CITY TN
37604-6034
US

IV. Provider business mailing address

335 WAYLAND DR
GREENEVILLE TN
37743-5950
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-7111
  • Fax:
Mailing address:
  • Phone: 423-620-8987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: