Healthcare Provider Details

I. General information

NPI: 1447255096
Provider Name (Legal Business Name): ELIZABETH A PARK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2005
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 HIGHWAY 411
VONORE TN
37885-2455
US

IV. Provider business mailing address

1206 HIGHWAY 411
VONORE TN
37885-2455
US

V. Phone/Fax

Practice location:
  • Phone: 423-442-2622
  • Fax: 423-442-5760
Mailing address:
  • Phone: 423-442-2622
  • Fax: 423-442-5760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6439
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: