=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588746978
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLYN PATTERSON GILLENWATER RD,CNSD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | JAMES H. QUILLEN/VAMC CORNER OF SIDNEY AND LAMONT
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-979-2928
-----------------------------------------------------
Fax | 423-979-3402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 175 MOORE RD
-----------------------------------------------------
City | JONESBOROUGH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37659-3856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-753-7211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 372037
-----------------------------------------------------
License Number State |
-----------------------------------------------------