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General NPI Number Information
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NPI Number | 1245002690
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Entity Type | Organization
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Legal Business Name | MIND BODY BEAUTY
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Dates
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Enumeration Date | 10/27/2023
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Last Update Date | 10/27/2023
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Provider Practice Location Address
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Address Line | 950 MAIN ST STE E
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City | WARTBURG
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State | TN
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Zip | 37887-4310
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Country | US
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Telephone | 865-410-4611
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Fax |
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Provider Business Mailing Address
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Address Line | 384 LANCER RD
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City | HARRIMAN
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State | TN
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Zip | 37748-4834
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Country | US
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Telephone | 865-335-0331
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AMANDA WALLS
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Credential |
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Telephone | 865-335-0331
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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