=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023155546
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JO LEE DEVANE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 N OCOEE ST LEE UNIVERSITY HEALTH CLINIC
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37311-4458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-614-8430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3011 CHESTNUT CIR NW
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37312-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-478-2417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 012009
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------