1649205907 NPI number — PAULA COUNTISS FNP

Table of content: PAULA COUNTISS FNP (NPI 1649205907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649205907 NPI number — PAULA COUNTISS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COUNTISS
Provider First Name:
PAULA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1649205907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2050 MEADOWVIEW PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37660-7332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-230-5000
Provider Business Mailing Address Fax Number:
423-230-5010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 MEDICAL PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE 458-W
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37620-7430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-844-4975
Provider Business Practice Location Address Fax Number:
423-844-4987
Provider Enumeration Date:
07/12/2006

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: 363L00000X , with the licence number:  5263 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 5263 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3345927 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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