=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841873718
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEDEDIAH A GILLIAM FNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2021
-----------------------------------------------------
Last Update Date | 11/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 809 LAMONT ST
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-5453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-926-1171
-----------------------------------------------------
Fax | 423-979-3685
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 216 TIMBERLAND CIR
-----------------------------------------------------
City | KINGSPORT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37664-5359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-677-5824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 29204
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------