=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346718020
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURI MICHELLE GINGERICH CPNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2018
-----------------------------------------------------
Last Update Date | 01/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 W CLINCH AVE
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37916-2219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-637-7920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 405 HIALEAH DR
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37920-5007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-536-6312
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 25413
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------