Provider Demographics
NPI:1033763081
Name:GANNON, CAITLIN (MSN, APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:
Other - Last Name:SIMINERIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6450 PROVISION CARES WAY
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2544
Mailing Address - Country:US
Mailing Address - Phone:865-862-1600
Mailing Address - Fax:
Practice Address - Street 1:6450 PROVISION CARES WAY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-2544
Practice Address - Country:US
Practice Address - Phone:865-862-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000026176363LP2300X
TN26176363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ055524Medicaid