Provider Demographics
NPI:1336503564
Name:GARNET HEALTH PROVIDER LLC
Entity Type:Organization
Organization Name:GARNET HEALTH PROVIDER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LIESL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:901-758-0280
Mailing Address - Street 1:PO BOX 381531
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-1531
Mailing Address - Country:US
Mailing Address - Phone:901-417-1779
Mailing Address - Fax:
Practice Address - Street 1:4493 POTTERS CROSS DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-4421
Practice Address - Country:US
Practice Address - Phone:901-336-8486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-13
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11962363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ020954Medicaid
TN103G705244Medicare PIN