Provider Demographics
NPI:1437382751
Name:SENGSAYADETH, SOUTHIDA (FNP)
Entity Type:Individual
Prefix:
First Name:SOUTHIDA
Middle Name:
Last Name:SENGSAYADETH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SOUTHIDA
Other - Middle Name:
Other - Last Name:BATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5431 EDMONDSON PIKE STE 10
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-5806
Mailing Address - Country:US
Mailing Address - Phone:615-896-1022
Mailing Address - Fax:615-896-1092
Practice Address - Street 1:2705 OLD FORT PKWY STE G
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128-5154
Practice Address - Country:US
Practice Address - Phone:615-896-1022
Practice Address - Fax:615-896-1092
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14259363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1504202Medicaid