{
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"FirstLineMailingAddress": "88 W EDAN RD",
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"MailingAddressCityName": "ETHRIDGE",
"MailingAddressStateName": "TN",
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"EnumerationDate": "08/24/2018",
"LastUpdateDate": "08/21/2024",
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"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "NISWANDER",
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"AuthorizedOfficialCredential": "NP",
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"Taxonomies": {
"Taxonomy": {
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"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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}
}
}
}