Healthcare Provider Details

I. General information

NPI: 1649500083
Provider Name (Legal Business Name): RITA CAROL KOON FNP BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2010
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 SHERRILL ST STE B
UNION CITY TN
38261-5891
US

IV. Provider business mailing address

702 SHERRILL ST STE B
UNION CITY TN
38261-5891
US

V. Phone/Fax

Practice location:
  • Phone: 731-885-8884
  • Fax:
Mailing address:
  • Phone: 731-885-8884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0000014862
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN0000106605
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: