Provider Demographics
NPI:1508860917
Name:GOURLEY, LINDA SUSAN (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:SUSAN
Last Name:GOURLEY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:SUSAN
Other - Last Name:SMOAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1059 E HIGHWAY 11 E
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-4910
Mailing Address - Country:US
Mailing Address - Phone:865-375-6005
Mailing Address - Fax:865-471-0244
Practice Address - Street 1:1059 E HIGHWAY 11 E
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-4910
Practice Address - Country:US
Practice Address - Phone:865-375-6005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN5899363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3907807Medicaid
TNP20688Medicare UPIN
3907807Medicare ID - Type Unspecified