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General NPI Number Information
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NPI Number | 1790113553
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Entity Type | Organization
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Legal Business Name | HOMETOWN FAMILY CARE, LLC
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Dates
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Enumeration Date | 10/14/2013
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Last Update Date | 03/06/2014
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Provider Practice Location Address
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Address Line | 675 B SOUTH JEFFERSON AVENUE
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City | COOKEVILLE
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State | TN
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Zip | 38501-0950
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Country | US
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Telephone | 931-854-0050
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Fax | 931-854-0411
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Provider Business Mailing Address
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Address Line | 675 B SOUTH JEFFERSON AVENUE
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City | COOKEVILLE
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State | TN
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Zip | 38501-0950
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Country | US
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Telephone | 931-854-0050
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Fax | 931-854-0411
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Authorized Official
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Title or Position | OWNER/PRACTITIONER
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Name | WANDA FAYE KEAGLE
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Credential | MSN, FNP
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Telephone | 931-854-0050
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | ANP 16167
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License Number State | TN
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