Healthcare Provider Details

I. General information

NPI: 1225374325
Provider Name (Legal Business Name): LANCE DYSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2012
Last Update Date: 12/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 6TH AVE N
NASHVILLE TN
37208-2650
US

IV. Provider business mailing address

206 DINWIDDIE DR
MADISON TN
37115-2460
US

V. Phone/Fax

Practice location:
  • Phone: 615-460-4100
  • Fax:
Mailing address:
  • Phone: 901-490-5276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number172V00000X
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: