Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081P2900X | Pain Medicine | 0000008007 | TN |
NPI | 1245267095 |
---|---|
Provider Name | Cheryl Conrad |
First Address | Jonesborough, TN 37659-6454 |
Second Address | Johnson City, TN 37604-4007 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4122083 | BLUE CROSS BLUE SHIELD (01) | TN |
P40216 | (02) | TN |
TN0130 | JOHN DEERE HEALTHCARE (01) | TN |