Healthcare Provider Details

I. General information

NPI: 1760718282
Provider Name (Legal Business Name): BLAKE SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2009
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 ENOCH BLVD
SAVANNAH TN
38372
US

IV. Provider business mailing address

3285 OAKLEY RD
SAVANNAH TN
38372-3807
US

V. Phone/Fax

Practice location:
  • Phone: 731-926-9600
  • Fax:
Mailing address:
  • Phone: 731-698-1061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN0000161004
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number24523
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: