=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780222349
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH RAE GUTIERREZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2019
-----------------------------------------------------
Last Update Date | 05/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1310 24TH AVE S
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37212-2637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-271-3886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 432 SHEAS WAY
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37043-1673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-271-3886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 26809
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------