1790410074 NPI number — REGHAN W MADDOX FNP

Table of content: REGHAN W MADDOX FNP (NPI 1790410074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790410074 NPI number — REGHAN W MADDOX FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADDOX
Provider First Name:
REGHAN
Provider Middle Name:
W
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:
1790410074
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1021 W OAKLAND AVE STE 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37604-2192
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-302-6567
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1410 TUSCULUM BLVD STE 2200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENEVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37745-5822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-639-0243
Provider Business Practice Location Address Fax Number:
423-639-0628
Provider Enumeration Date:
07/20/2022

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:  32122 , 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)