Healthcare Provider Details

I. General information

NPI: 1831572809
Provider Name (Legal Business Name): WEST SIDE WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9957 KINGSTON PIKE STE. 105
KNOXVILLE TN
37922-6908
US

IV. Provider business mailing address

9957 KINGSTON PIKE STE. 105
KNOXVILLE TN
37922-6908
US

V. Phone/Fax

Practice location:
  • Phone: 865-862-4575
  • Fax: 865-862-4574
Mailing address:
  • Phone: 865-862-4575
  • Fax: 865-862-4574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1994
License Number StateTN

VIII. Authorized Official

Name: JANET DEESE
Title or Position: OWNER
Credential:
Phone: 865-862-4575