Provider Demographics
NPI:1124387857
Name:WARD, BECCA JO (NP)
Entity Type:Individual
Prefix:MS
First Name:BECCA
Middle Name:JO
Last Name:WARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:1167 SPRATLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-6205
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:109 W WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5621
Practice Address - Country:US
Practice Address - Phone:423-232-2600
Practice Address - Fax:423-467-3644
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20144363LP0808X
VA0024172778363LP0808X
IN28175679A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400075287Medicare PIN
VAVVI502B288Medicare PIN
TN1035I07723Medicare PIN