Healthcare Provider Details

I. General information

NPI: 1255477741
Provider Name (Legal Business Name): JANET ELDRIDGE ISHAM LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1362 N. GATEWAY AVE
ROCKWOOD TN
37854
US

IV. Provider business mailing address

1362 N. GATEWAY AVE
ROCKWOOD TN
37854
US

V. Phone/Fax

Practice location:
  • Phone: 865-354-1220
  • Fax: 865-354-0112
Mailing address:
  • Phone: 865-354-1220
  • Fax: 865-354-0112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN0000025757
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: