Provider Demographics
NPI:1184011835
Name:GIST, KHAISHA VERDELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:KHAISHA
Middle Name:VERDELLE
Last Name:GIST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KHAISHA
Other - Middle Name:VERDELLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2723 NEW SALEM HWY
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37128-5253
Mailing Address - Country:US
Mailing Address - Phone:615-410-9360
Mailing Address - Fax:833-944-2291
Practice Address - Street 1:5380 HICKORY HOLLOW PKWY STE 205
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-3389
Practice Address - Country:US
Practice Address - Phone:615-412-8662
Practice Address - Fax:615-270-2493
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2023-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN57747207Q00000X
TNMD0000057747207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNMD0000057747OtherTN LICENSE
TN1184011835OtherRESIDENT/TRAINING PROGRAM