=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326487752
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETHANY RANDOLPH HOGAN APN-FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2013
-----------------------------------------------------
Last Update Date | 02/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5520 HIGH ST
-----------------------------------------------------
City | OOLTEWAH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37363-8131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-209-5440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 921 E 3RD ST
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37403-2102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-209-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 17711
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------