Provider Demographics
NPI:1114425501
Name:TANKERSLEY, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:TANKERSLEY
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 1:404 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4613
Mailing Address - Country:US
Mailing Address - Phone:865-238-4224
Mailing Address - Fax:
Practice Address - Street 1:108 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5740
Practice Address - Country:US
Practice Address - Phone:865-238-4224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17334225700000X
TNMT10893225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist