Provider Demographics
NPI:1073830147
Name:HUNTLAND CLINIC, PLLC
Entity Type:Organization
Organization Name:HUNTLAND CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:931-469-0303
Mailing Address - Street 1:P O BOX 141
Mailing Address - Street 2:
Mailing Address - City:HUNTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37345
Mailing Address - Country:US
Mailing Address - Phone:931-469-0303
Mailing Address - Fax:931-469-0802
Practice Address - Street 1:707 MAIN ST
Practice Address - Street 2:
Practice Address - City:HUNTLAND
Practice Address - State:TN
Practice Address - Zip Code:37345-3263
Practice Address - Country:US
Practice Address - Phone:931-469-0303
Practice Address - Fax:931-469-0802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7935363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty