Healthcare Provider Details

I. General information

NPI: 1619246873
Provider Name (Legal Business Name): DEBORAH WYATT GADDIS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2011
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 MOUNTAIN VIEW DR SUITE A
KIMBALL TN
37347-5477
US

IV. Provider business mailing address

24 MOUNTAIN VIEW DR SUITE A
KIMBALL TN
37347-5477
US

V. Phone/Fax

Practice location:
  • Phone: 423-942-9171
  • Fax: 423-942-9128
Mailing address:
  • Phone: 423-942-9171
  • Fax: 423-942-9128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16232
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: