Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 56994 | TN |
NPI | 1033733605 |
---|---|
Provider Name | Justin Meredith |
First Address | Cub Run, KY 42729-9338 |
Second Address | Cub Run, KY 42729-9338 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/05/2020 |
Last Update Date | 29/05/2020 |