Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC1500X | Nurse Practitioner - Community Health | 13815 | TN |
NPI | 1326283011 |
---|---|
Provider Name | Laurin Revere Wheaton |
First Address | Franklin, TN 37067-2678 |
Second Address | Franklin, TN 37067-2678 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/12/2008 |
Last Update Date | 29/07/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1510016 | (05) | TN |
1510016 | MCC-MEDICAID-TN (01) | TN |