=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689526741
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED FACIAL AESTHETICS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2026
-----------------------------------------------------
Last Update Date | 02/11/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1821 N WASHINGTON ST
-----------------------------------------------------
City | TULLAHOMA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37388-2221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-455-2005
-----------------------------------------------------
Fax | 931-455-4450
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1821 N WASHINGTON ST
-----------------------------------------------------
City | TULLAHOMA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37388-2221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-455-2005
-----------------------------------------------------
Fax | 931-455-4450
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING FACILITATOR
-----------------------------------------------------
Name | TRACY HICKERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 931-461-5056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207YX0905X
-----------------------------------------------------
Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------