Provider Demographics
NPI:1407492572
Name:CARROLL, SAVANNAH BROOKE
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:BROOKE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 LAKE CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-5222
Mailing Address - Country:US
Mailing Address - Phone:931-581-9576
Mailing Address - Fax:
Practice Address - Street 1:1801 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-8259
Practice Address - Country:US
Practice Address - Phone:931-393-7833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26655363LA2100X
TN0000026655363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care