Provider Demographics
NPI:1568923944
Name:BORK, RHENNETTA (DPM)
Entity Type:Individual
Prefix:
First Name:RHENNETTA
Middle Name:
Last Name:BORK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 WALLACE RD STE 411
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-8028
Mailing Address - Country:US
Mailing Address - Phone:615-332-0330
Mailing Address - Fax:
Practice Address - Street 1:1503 HATCHER LN STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4833
Practice Address - Country:US
Practice Address - Phone:931-388-9922
Practice Address - Fax:615-332-0340
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN925213ES0131X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ075257Medicaid