Healthcare Provider Details

I. General information

NPI: 1427541309
Provider Name (Legal Business Name): ADRIENNE N OFFUTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ADRIENNE BLACK

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 W REELFOOT AVE
UNION CITY TN
38261-5569
US

IV. Provider business mailing address

PO BOX 1258
WAYNESBORO TN
38485-1258
US

V. Phone/Fax

Practice location:
  • Phone: 931-253-1110
  • Fax:
Mailing address:
  • Phone: 931-253-1110
  • Fax: 931-722-9919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number24174
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3012300
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: