Healthcare Provider Details

I. General information

NPI: 1346310067
Provider Name (Legal Business Name): GREGORY VANFOSSEN N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4957 SWINYAR DR STE 101
OOLTEWAH TN
37363-2205
US

IV. Provider business mailing address

3774 BLUE SPRINGS RD
CLEVELAND TN
37311-8827
US

V. Phone/Fax

Practice location:
  • Phone: 423-698-0850
  • Fax: 833-450-6311
Mailing address:
  • Phone: 786-818-9004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21795
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number21795
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: