=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477121168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NURSE DEBI'S HEALTH & WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2021
-----------------------------------------------------
Last Update Date | 06/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2319 W EMORY RD
-----------------------------------------------------
City | POWELL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37849-3708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-340-6346
-----------------------------------------------------
Fax | 865-859-9156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2319 W EMORY RD
-----------------------------------------------------
City | POWELL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37849-3708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-340-6346
-----------------------------------------------------
Fax | 865-859-9156
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP / OPERATIONS MANAGER
-----------------------------------------------------
Name | GLEN STAFFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 802-922-0893
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------