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General NPI Number Information
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NPI Number | 1003520966
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Entity Type | Organization
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Legal Business Name | SOUTHWELL MEDICAL LLC.
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Dates
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Enumeration Date | 01/05/2023
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Last Update Date | 01/05/2023
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Provider Practice Location Address
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Address Line | 207 LAKE FOREST DR
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City | KNOXVILLE
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State | TN
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Zip | 37920-5144
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Country | US
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Telephone | 865-455-4817
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Fax |
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Provider Business Mailing Address
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Address Line | 207 LAKE FOREST DR
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City | KNOXVILLE
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State | TN
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Zip | 37920-5144
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Country | US
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Telephone | 865-455-4817
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. JAKE HARRISON
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Credential | FNP
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Telephone | 865-455-4817
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213EP1101X
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Taxonomy Name | Primary Podiatric Medicine Podiatrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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