Healthcare Provider Details

I. General information

NPI: 1619591237
Provider Name (Legal Business Name): JANICE NEWSOM PROVIDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200B BUCHANAN ST # 2200B
NASHVILLE TN
37208-1912
US

IV. Provider business mailing address

2200B BUCHANAN ST # 2200B
NASHVILLE TN
37208-1912
US

V. Phone/Fax

Practice location:
  • Phone: 615-609-1472
  • Fax:
Mailing address:
  • Phone: 615-609-1472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number74749216
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number13012807
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: