Healthcare Provider Details

I. General information

NPI: 1417296807
Provider Name (Legal Business Name): CHRISTINE CORPUZ KOWAL FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 W BADDOUR PKWY
LEBANON TN
37087-2513
US

IV. Provider business mailing address

1407 W BADDOUR PKWY
LEBANON TN
37087-2513
US

V. Phone/Fax

Practice location:
  • Phone: 615-444-6203
  • Fax: 615-444-6252
Mailing address:
  • Phone: 615-444-6203
  • Fax: 615-444-6252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17209
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: