1699176750 NPI number — JACKIE WILSON-SHARP FNP

Table of content: JACKIE WILSON-SHARP FNP (NPI 1699176750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699176750 NPI number — JACKIE WILSON-SHARP FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON-SHARP
Provider First Name:
JACKIE
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:
1699176750
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
470 INDUSTRIAL LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ONEIDA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37841-6294
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-286-4141
Provider Business Mailing Address Fax Number:
423-286-4145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3826 NORMA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37756-4408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-663-2920
Provider Business Practice Location Address Fax Number:
423-663-3989
Provider Enumeration Date:
09/09/2014

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:  19046 , 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: Q017081 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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