Provider Demographics
NPI:1396216339
Name:FOUNTAIN OF YOUTH MEDICAL LLC
Entity Type:Organization
Organization Name:FOUNTAIN OF YOUTH MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP-C
Authorized Official - Prefix:
Authorized Official - First Name:GENEVA
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:WORTHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:865-392-1500
Mailing Address - Street 1:135 LOVELL RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-1904
Mailing Address - Country:US
Mailing Address - Phone:865-392-1500
Mailing Address - Fax:865-392-1402
Practice Address - Street 1:135 LOVELL RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-1904
Practice Address - Country:US
Practice Address - Phone:865-392-1400
Practice Address - Fax:865-392-1402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty