Healthcare Provider Details

I. General information

NPI: 1407579931
Provider Name (Legal Business Name): AMY LEIGH GRYDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9352 PARK WEST BLVD
KNOXVILLE TN
37923-4325
US

IV. Provider business mailing address

3334 SONG SPARROW DR
MARYVILLE TN
37803-6905
US

V. Phone/Fax

Practice location:
  • Phone: 865-373-1000
  • Fax:
Mailing address:
  • Phone: 252-266-8761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number32024
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: