MEDICARE: MS. AWILDA MARRERO LABONNE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	03307	TN
2	363AM0700X	Medical Physician Assistant	03307	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	363AMO700X	OTHER	IL	TAXONOMY

General Provider Information

NPI Number	:	1114986593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AWILDA MARRERO LABONNE PA-C

Provider Business Mailing Address
First Line	:	13 W KENT ST STE 103
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37405-9913
Country	:	US
Telephone Number	:	423-648-2273
Fax Number	:	423-206-4625

Provider Business Practice Location Address
First Line	:	13 W KENT ST STE 103
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37405-9913
Country	:	US
Telephone Number	:	423-648-2273
Fax Number	:	423-206-4625

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2006
Last Update Date	:	03/07/2023

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