MEDICARE: WILLOW MEDICAL CLINIC, LLC

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	363LF0000X	Family Nurse Practitioner
2	363AM0700X	Medical Physician Assistant

General Provider Information

NPI Number	:	1356507404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW MEDICAL CLINIC, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1223
Second Line	:
City	:	MANCHESTER
State	:	TN
Zip	:	37349-1223
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 WILLOW DR
Second Line	:
City	:	MANCHESTER
State	:	TN
Zip	:	37355-2438
Country	:	US
Telephone Number	:	931-728-7677
Fax Number	:	931-728-7066

Authorized Official
Title or Position	:	OFFICE MANAGER/ASSIST. BUSINESS ADM
Name	:	MS. TAMMY SHELLEY
Credential	:
Telephone Number	:	931-570-4755

Provider Enumeration Date	:	07/29/2008
Last Update Date	:	07/29/2008

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Directions to “WILLOW MEDICAL CLINIC, LLC ” Practice Location

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