Healthcare Provider Details

I. General information

NPI: 1588122428
Provider Name (Legal Business Name): BRENDA JEAN PRICE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MCGHEE ST
MARYVILLE TN
37801-6811
US

IV. Provider business mailing address

301 MCGHEE ST
MARYVILLE TN
37801-6811
US

V. Phone/Fax

Practice location:
  • Phone: 865-983-4582
  • Fax: 865-983-4574
Mailing address:
  • Phone: 865-983-4582
  • Fax: 865-983-4574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number122772
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: