Provider Demographics
NPI:1629304340
Name:HYDER, SALLY ANN (ANP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:HYDER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 N STATE OF FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6034
Mailing Address - Country:US
Mailing Address - Phone:423-431-7047
Mailing Address - Fax:423-979-0569
Practice Address - Street 1:403 N STATE OF FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6034
Practice Address - Country:US
Practice Address - Phone:423-431-7047
Practice Address - Fax:423-979-0569
Is Sole Proprietor?:No
Enumeration Date:2009-10-30
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000005082363LA2200X
TN5082363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1517566Medicaid
TN103I502439Medicare PIN
VA1629304340Medicaid