=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457726374
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GIBBS FAMILY PRACTICE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2015
-----------------------------------------------------
Last Update Date | 05/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7331 TAZEWELL PIKE
-----------------------------------------------------
City | CORRYTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37721-3516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-249-8044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7331 TAZEWELL PIKE
-----------------------------------------------------
City | CORRYTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37721-3516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-249-8044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | MRS. LESLIE HEISER
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 865-249-8044
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APN17718
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------