=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902627169
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMOKEY MOUNTAIN MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2024
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 163 PERKINS LN
-----------------------------------------------------
City | JACKSBORO
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37757-2833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-592-0422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 163 PERKINS LN
-----------------------------------------------------
City | JACKSBORO
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37757-2833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-592-0422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANTHONY KINGSLEY
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 423-592-0422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------