Provider Demographics
NPI:1144742842
Name:WESTSIDE FAMILY MEDICAL
Entity Type:Organization
Organization Name:WESTSIDE FAMILY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:931-636-3176
Mailing Address - Street 1:160 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37398-2566
Mailing Address - Country:US
Mailing Address - Phone:931-636-3176
Mailing Address - Fax:
Practice Address - Street 1:104 WESTSIDE DR
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-3253
Practice Address - Country:US
Practice Address - Phone:931-636-3176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20413363LF0000X
TN19352363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1255720421Medicaid
TN1053780478Medicaid