Provider Demographics
NPI:1518915958
Name:CONERLY, JENIFER C (NP)
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:C
Last Name:CONERLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENIFER
Other - Middle Name:N
Other - Last Name:CONERLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1 MEDICAL PARK BLVD
Mailing Address - Street 2:TRAUMA SERVICES
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-7430
Mailing Address - Country:US
Mailing Address - Phone:423-844-2139
Mailing Address - Fax:423-844-2109
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:TRAUMA SERVICES
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-844-2139
Practice Address - Fax:423-844-2109
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7932363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P82179Medicare UPIN