Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | 207Q00000X | TN |
NPI | 1326170473 |
---|---|
Provider Name | Dr. Terri R Brunvoll |
First Address | Hixson, TN 37343-7916 |
Second Address | Hixson, TN 37343-7916 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/03/2007 |
Last Update Date | 22/03/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
080157953 | MEDICARE RR (01) | TN |
5064580 | (05) | TN |
DO0000001148 | MEDICAL LICENSE (01) | TN |
F51312 | (02) | TN |