=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720733462
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ELIZABETH STILL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2022
-----------------------------------------------------
Last Update Date | 01/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 721 GLENWOOD DR STE W550
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37404-1155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-698-8692
-----------------------------------------------------
Fax | 423-624-7813
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 721 GLENWOOD DR STE W550
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37404-1155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-698-8692
-----------------------------------------------------
Fax | 423-624-7813
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 4876
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------