Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 1434 | TN |
N | 207Q00000X | Family Doctor | 1434 | TN |
NPI | 1164519880 |
---|---|
Provider Name | Coleen Marie Smith |
First Address | Johnson City, TN 37604-3844 |
Second Address | Johnson City, TN 37604-3844 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4043727 | BLUE CROSS/ BLUE SHIELD (01) | TN |
E79125 | (02) | TN |