=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184162000
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NANCY D. COGBURN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2017
-----------------------------------------------------
Last Update Date | 02/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1759 SCENIC DR
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37803-5535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-654-2069
-----------------------------------------------------
Fax | 865-233-2476
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4471
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37802-4471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-654-2069
-----------------------------------------------------
Fax | 865-233-2476
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NANCY COGBURN
-----------------------------------------------------
Credential | P.T., D.P.T.
-----------------------------------------------------
Telephone | 865-654-2069
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 0000010045
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------