MEDICARE: SHEENA L TULLOCK FNP

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	363L00000X	Nurse Practitioner	24091	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	24091	OTHER	TN	APN LICENSE

General Provider Information

NPI Number	:	1356831101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHEENA L TULLOCK FNP

Provider Business Mailing Address
First Line	:	6701 BAUM DR STE 140
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37919-7361
Country	:	US
Telephone Number	:	865-584-5727
Fax Number	:	865-450-9904

Provider Business Practice Location Address
First Line	:	2428 KNOB CREEK RD STE 102
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-2396
Country	:	US
Telephone Number	:	423-794-1074
Fax Number	:	423-794-1079

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

Provider Enumeration Date	:	05/17/2018
Last Update Date	:	10/05/2018

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