Provider Demographics
NPI:1518937069
Name:HUMPHREYS, DANIELLE O (FNP)
Entity Type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:O
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:M
Other - Last Name:OVERTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:135 W RAVINE RD
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3847
Mailing Address - Country:US
Mailing Address - Phone:423-246-6777
Mailing Address - Fax:423-746-7766
Practice Address - Street 1:235 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7455
Practice Address - Country:US
Practice Address - Phone:423-246-6777
Practice Address - Fax:423-246-7766
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN08353363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4212285OtherBCBS
TN3700035Medicaid
VA010316634Medicaid
VA010316634Medicaid
TN3700035Medicaid