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General NPI Number Information
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NPI Number | 1356507404
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Entity Type | Organization
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Legal Business Name | WILLOW MEDICAL CLINIC, LLC
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Dates
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Enumeration Date | 07/29/2008
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Last Update Date | 07/29/2008
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Provider Practice Location Address
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Address Line | 1400 WILLOW DR
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City | MANCHESTER
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State | TN
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Zip | 37355-2438
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Country | US
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Telephone | 931-728-7677
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Fax | 931-728-7066
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Provider Business Mailing Address
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Address Line | PO BOX 1223
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City | MANCHESTER
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State | TN
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Zip | 37349-1223
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER/ASSIST. BUSINESS ADM
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Name | MS. TAMMY SHELLEY
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Credential |
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Telephone | 931-570-4755
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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