Provider Demographics
NPI:1326430620
Name:LEGENS, ERIN NICOLE
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:NICOLE
Last Name:LEGENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:NICOLE
Other - Last Name:LEGENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:205 HOSPITAL DR STE A
Mailing Address - Street 2:
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-1649
Mailing Address - Country:US
Mailing Address - Phone:731-352-7907
Mailing Address - Fax:731-352-4459
Practice Address - Street 1:136 S WILSON ST
Practice Address - Street 2:
Practice Address - City:DRESDEN
Practice Address - State:TN
Practice Address - Zip Code:38225-1133
Practice Address - Country:US
Practice Address - Phone:731-364-4900
Practice Address - Fax:731-352-4459
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19668363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ015130Medicaid
TN3380640Medicaid