Healthcare Provider Details

I. General information

NPI: 1053222927
Provider Name (Legal Business Name): TAGUE MCILLWAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 BRIARVILLE RD
MADISON TN
37115-5145
US

IV. Provider business mailing address

331 INDIAN LAKE RD
HENDERSONVILLE TN
37075-4537
US

V. Phone/Fax

Practice location:
  • Phone: 615-410-4990
  • Fax:
Mailing address:
  • Phone: 615-852-9303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number42084
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: