Healthcare Provider Details

I. General information

NPI: 1184011835
Provider Name (Legal Business Name): KHAISHA VERDELLE GIST M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KHAISHA VERDELLE JOHNSON M.D.

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 PRESIDENT PL STE 140
SMYRNA TN
37167-6808
US

IV. Provider business mailing address

PO BOX 23
GLADEVILLE TN
37071-0023
US

V. Phone/Fax

Practice location:
  • Phone: 615-412-9013
  • Fax: 615-307-4064
Mailing address:
  • Phone: 615-412-9018
  • Fax: 615-307-4064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number57747
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD0000057747
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: