Healthcare Provider Details

I. General information

NPI: 1689677395
Provider Name (Legal Business Name): STEPHANIE TIPTON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W STONE DR STE 2A
KINGSPORT TN
37660-3256
US

IV. Provider business mailing address

PO BOX 9
KINGSPORT TN
37662-0009
US

V. Phone/Fax

Practice location:
  • Phone: 423-230-2420
  • Fax: 423-378-5940
Mailing address:
  • Phone: 423-857-2066
  • Fax: 423-857-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN6186
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: