Healthcare Provider Details

I. General information

NPI: 1447926589
Provider Name (Legal Business Name): MABREY RAYMOND DUFF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3206 KINGSMORE DR
KNOXVILLE TN
37921-1450
US

IV. Provider business mailing address

3206 KINGSMORE DR
KNOXVILLE TN
37921-1450
US

V. Phone/Fax

Practice location:
  • Phone: 865-803-8981
  • Fax: 865-522-3062
Mailing address:
  • Phone: 865-803-8981
  • Fax: 865-522-3062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number998T2B
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: