1518521772 NPI number — TARRA BERGERON LANDRY HERNANDEZ FNP-BC

Table of content: TARRA BERGERON LANDRY HERNANDEZ FNP-BC (NPI 1518521772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518521772 NPI number — TARRA BERGERON LANDRY HERNANDEZ FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERNANDEZ
Provider First Name:
TARRA
Provider Middle Name:
BERGERON LANDRY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
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:
1518521772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 WESTWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37415-2316
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-260-6357
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6624 LEE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37421-2421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-648-8008
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2019

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:  25696 , 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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