Provider Demographics
NPI:1073046587
Name:WELLCARE FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:WELLCARE FAMILY MEDICINE PLLC
Other - Org Name:ANGELA BUCKNER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:BUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:423-949-9355
Mailing Address - Street 1:517 RUSSELL ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:DUNLAP
Mailing Address - State:TN
Mailing Address - Zip Code:37327-3648
Mailing Address - Country:US
Mailing Address - Phone:423-949-9355
Mailing Address - Fax:423-949-9358
Practice Address - Street 1:517 RUSSELL ST
Practice Address - Street 2:SUITE C
Practice Address - City:DUNLAP
Practice Address - State:TN
Practice Address - Zip Code:37327-3648
Practice Address - Country:US
Practice Address - Phone:423-949-9355
Practice Address - Fax:423-949-9358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN16901363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1529434Medicaid
TN103I50557Medicare Oscar/Certification