MEDICARE: KRISTY ALESE HENEGAR

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	APN0000024431	TN

General Provider Information

NPI Number	:	1487134482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTY ALESE HENEGAR

Provider Business Mailing Address
First Line	:	1420 FRITZ ST SE
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37323-6009
Country	:	US
Telephone Number	:	423-478-1970
Fax Number	:

Provider Business Practice Location Address
First Line	:	1420 FRITZ ST SE
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37323
Country	:	US
Telephone Number	:	423-478-1970
Fax Number	:

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

Provider Enumeration Date	:	08/19/2018
Last Update Date	:	08/31/2018

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