Provider Demographics
NPI:1639696784
Name:TROUTT, TALISHA ETTINA LEEANN (FNP)
Entity Type:Individual
Prefix:
First Name:TALISHA
Middle Name:ETTINA LEEANN
Last Name:TROUTT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70403
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-1703
Mailing Address - Country:US
Mailing Address - Phone:423-439-4381
Mailing Address - Fax:423-439-4543
Practice Address - Street 1:365 STOUT DRIVE
Practice Address - Street 2:SUITE 160
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37614-3761
Practice Address - Country:US
Practice Address - Phone:423-439-4225
Practice Address - Fax:423-439-4560
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23083363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ036951Medicaid