Provider Demographics
NPI:1649742149
Name:MANTOOTH, CYNTHIA DIANE (APRN)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:DIANE
Last Name:MANTOOTH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:DIANE
Other - Last Name:BUCKNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6350 W ANDREW JOHNSON HWY
Mailing Address - Street 2:
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:815 W 5TH NORTH ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3810
Practice Address - Country:US
Practice Address - Phone:423-586-5032
Practice Address - Fax:423-581-8473
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN165055163W00000X
TN25247363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse