=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003260191
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONNIE T RUTLEDGE NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2016
-----------------------------------------------------
Last Update Date | 02/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 MED TECH PKWY STE 100
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-2392
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-282-5611
-----------------------------------------------------
Fax | 423-282-5712
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 632476
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45263-2476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-282-5611
-----------------------------------------------------
Fax | 423-282-5712
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 0024173715
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 21086
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------