Healthcare Provider Details

I. General information

NPI: 1356507404
Provider Name (Legal Business Name): WILLOW MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 WILLOW DR
MANCHESTER TN
37355-2438
US

IV. Provider business mailing address

PO BOX 1223
MANCHESTER TN
37349-1223
US

V. Phone/Fax

Practice location:
  • Phone: 931-728-7677
  • Fax: 931-728-7066
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. TAMMY SHELLEY
Title or Position: OFFICE MANAGER/ASSIST. BUSINESS ADM
Credential:
Phone: 931-570-4755