1578718342 NPI number — MS. AMY BRADSHAW GLASS ACNP

Table of content: MS. AMY BRADSHAW GLASS ACNP (NPI 1578718342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578718342 NPI number — MS. AMY BRADSHAW GLASS ACNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLASS
Provider First Name:
AMY
Provider Middle Name:
BRADSHAW
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
ACNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578718342
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1904 ALCOA HWY
Provider Second Line Business Mailing Address:
SUITE 210 E
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-524-7471
Provider Business Mailing Address Fax Number:
865-305-6563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1940 ALCOA HWY
Provider Second Line Business Practice Location Address:
SUITE E - 210
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37920-2244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-524-7471
Provider Business Practice Location Address Fax Number:
865-305-6563
Provider Enumeration Date:
11/20/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  150292 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: 13795 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1514111 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".