Healthcare Provider Details

I. General information

NPI: 1801477369
Provider Name (Legal Business Name): EAST NASHVILLE PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3926 GALLATIN PIKE STE B
NASHVILLE TN
37216-2436
US

IV. Provider business mailing address

1612 SUMNER AVE
NASHVILLE TN
37206-2536
US

V. Phone/Fax

Practice location:
  • Phone: 917-846-9609
  • Fax:
Mailing address:
  • Phone: 917-846-9609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. BREANNA LUSTRE
Title or Position: OWNER
Credential: MD
Phone: 615-882-4900