Provider Demographics
NPI:1679128243
Name:COTTRELL, MISTY DAWN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:COTTRELL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6471
Mailing Address - Country:US
Mailing Address - Phone:865-482-1777
Mailing Address - Fax:865-374-2117
Practice Address - Street 1:100 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6471
Practice Address - Country:US
Practice Address - Phone:865-482-1777
Practice Address - Fax:865-374-2117
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26262363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ055968Medicaid