Healthcare Provider Details

I. General information

NPI: 1811675960
Provider Name (Legal Business Name): CHARLES JACOB CUPP FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 DOHI DR
LOUDON TN
37774-2851
US

IV. Provider business mailing address

1275 DICK LONAS RD UNIT 101
KNOXVILLE TN
37909-1383
US

V. Phone/Fax

Practice location:
  • Phone: 865-205-3025
  • Fax: 833-908-2125
Mailing address:
  • Phone: 865-584-4747
  • Fax: 865-381-1509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number34212
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: