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East Tennessee State University

Organization Active NPI Primary Care Nurse Practitioner · Gray, TN

NPI 1033344007 · NPPES record last updated Feb 23, 2017

Key facts

NPI
1033344007
Entity type
Organization (NPI type 2)
Primary specialty
Primary Care Nurse Practitioner 363LP2300X
Legal business name
EAST TENNESSEE STATE UNIVERSITY
Practice address
1440 Suncrest Dr
Gray, TN 37615-4118
Phone
(423) 477-1634
Fax
(423) 477-1625
NPI assigned
May 20, 2009
Organization subpart
No

Authorized official

Name
Ms. Betty J. King
Title
Acting Chief Financial Officer
Phone
(423) 439-4414

Corporate family (same tax ID) 19

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
44D2171893Daniel Boone High School
1440 Suncrest Drive, Gray, TN 37615		Certificate of waiverSep 9, 2027

National Provider Directory

Tax ID family
East Tennessee State University (20 organizations share this tax ID)

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Nurse Practitioner
Group: 193400000X SINGLE SPECIALTY GROUP		 363LP2300X Yes

Addresses

Primary practice location

1440 Suncrest Dr
Gray, TN 37615-4118

Mailing address

365 Stout Drive Box 70403
Johnson City, TN 37614-1703
Phone (423) 439-4071

Other names

  • Daniel Boone High School Based Clinic Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Feb 23, 2017.

{
    "created_epoch": "1242777600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1487808000000",
    "number": "1033344007",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "365 STOUT DRIVE BOX 70403",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376141703",
            "telephone_number": "423-439-4071",
            "fax_number": "423-439-4060"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1440 SUNCREST DR",
            "city": "GRAY",
            "state": "TN",
            "postal_code": "376154118",
            "telephone_number": "423-477-1634",
            "fax_number": "423-477-1625"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST TENNESSEE STATE UNIVERSITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-05-20",
        "last_updated": "2017-02-23",
        "status": "A",
        "authorized_official_last_name": "KING",
        "authorized_official_first_name": "BETTY",
        "authorized_official_middle_name": "J.",
        "authorized_official_title_or_position": "ACTING CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "423-439-4414",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "363LP2300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Primary Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Daniel Boone High School Based Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Gray, TN

All providers in Gray, TN · Primary Care Nurse Practitioner in Tennessee

Sources for this page

Verify at the official NPI Registry.