Healthcare Provider Details

I. General information

NPI: 1306395264
Provider Name (Legal Business Name): BETHANY WHITE III AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 10/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 E WEISGARBER RD SUITE 100
KNOXVILLE TN
37909-2674
US

IV. Provider business mailing address

1128 E WEISGARBER RD SUITE 100
KNOXVILLE TN
37909-2674
US

V. Phone/Fax

Practice location:
  • Phone: 865-579-0552
  • Fax: 865-579-1154
Mailing address:
  • Phone: 865-579-0552
  • Fax: 865-579-1154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number21750
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number21750
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: