=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083226294
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAPHNE JIAYANG DENG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2020
-----------------------------------------------------
Last Update Date | 08/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1975 W ELK AVE STE 1
-----------------------------------------------------
City | ELIZABETHTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37643-3787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-543-0073
-----------------------------------------------------
Fax | 423-543-1277
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1975 W ELK AVE STE 1
-----------------------------------------------------
City | ELIZABETHTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37643-3787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-543-0073
-----------------------------------------------------
Fax | 423-543-1277
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 13142
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------