1104279983 NPI number — MRS. AUTUM MARIE SALSBURY FNP-C

Table of content: MRS. AUTUM MARIE SALSBURY FNP-C (NPI 1104279983)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104279983 NPI number — MRS. AUTUM MARIE SALSBURY FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SALSBURY
Provider First Name:
AUTUM
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MILES
Provider Other First Name:
AUTUM
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104279983
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1275 DICK LONAS RD UNIT 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37909-1383
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-584-4747
Provider Business Mailing Address Fax Number:
865-584-1363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1825 KNOXVILLE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARTBURG
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37887-4120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-346-3600
Provider Business Practice Location Address Fax Number:
833-908-2181
Provider Enumeration Date:
07/18/2016

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: 363LF0000X , with the licence number:  21523 , 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: Q024944 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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