=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114528049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENNESSEE TELEDERM PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2020
-----------------------------------------------------
Last Update Date | 11/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3500 JOHN A MERRITT BLVD
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-513-1959
-----------------------------------------------------
Fax | 615-513-0498
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 73 WHITE BRIDGE PIKE STE 103
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37205-1444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-513-1959
-----------------------------------------------------
Fax | 615-513-0498
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | STACY SNYDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-565-1132
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------