1790140648 NPI number — JANICE LEDFORD FNP

Table of content: JANICE LEDFORD FNP (NPI 1790140648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790140648 NPI number — JANICE LEDFORD FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEDFORD
Provider First Name:
JANICE
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:
1790140648
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2347 JONES BEND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37777-5213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-970-9800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1596 HIGHWAY 33 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW TAZEWELL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37825-7104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-626-8271
Provider Business Practice Location Address Fax Number:
865-342-0106
Provider Enumeration Date:
12/18/2015

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:  21152 , 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: Q020688 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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