Healthcare Provider Details

I. General information

NPI: 1679130652
Provider Name (Legal Business Name): DENISE LYNNE WILLER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 GALLAHER RD
KINGSTON TN
37763-4215
US

IV. Provider business mailing address

629 GALLAHER RD
KINGSTON TN
37763-4215
US

V. Phone/Fax

Practice location:
  • Phone: 865-376-3416
  • Fax:
Mailing address:
  • Phone: 865-376-3416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN112216
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: