Provider Demographics
NPI:1063861938
Name:PROVENCE, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:PROVENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8015 SODERLUND DR
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38053-5826
Mailing Address - Country:US
Mailing Address - Phone:901-489-3582
Mailing Address - Fax:
Practice Address - Street 1:139 WESLEY REED DR
Practice Address - Street 2:SUITE F
Practice Address - City:ATOKA
Practice Address - State:TN
Practice Address - Zip Code:38004-4905
Practice Address - Country:US
Practice Address - Phone:901-837-8801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6131183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist