1982737912 NPI number — MRS. JODY WIDNER HENDERSON RN-BC

Table of content: MRS. JODY WIDNER HENDERSON RN-BC (NPI 1982737912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982737912 NPI number — MRS. JODY WIDNER HENDERSON RN-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
JODY
Provider Middle Name:
WIDNER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WIDNER
Provider Other First Name:
JODY
Provider Other Middle Name:
YVONNE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1982737912
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1923 SULPHUR SPRINGS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORRISTOWN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37813-5654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-317-9344
Provider Business Mailing Address Fax Number:
423-714-2355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2018 WESTERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-544-0406
Provider Business Practice Location Address Fax Number:
865-544-0480
Provider Enumeration Date:
03/13/2007

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: 163WP0808X , with the licence number:  RN50310 , 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)





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