Healthcare Provider Details

I. General information

NPI: 1659795151
Provider Name (Legal Business Name): CHARLES ADAM WILLIS FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2014
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6419 BRISTOL HWY
PINEY FLATS TN
37686-5208
US

IV. Provider business mailing address

6419 BRISTOL HWY
PINEY FLATS TN
37686-5208
US

V. Phone/Fax

Practice location:
  • Phone: 423-538-5202
  • Fax: 423-538-8208
Mailing address:
  • Phone: 423-538-5202
  • Fax: 423-538-8208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN0000177156
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18377
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: