Provider Demographics
NPI:1710145537
Name:DERMATOLOGY ASSOC.OF OAK RIDGE,PC
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOC.OF OAK RIDGE,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APN-C
Authorized Official - Prefix:MS
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:APN-C
Authorized Official - Phone:865-813-1009
Mailing Address - Street 1:800 OAK RIDGE TPKE
Mailing Address - Street 2:SUITE A-300
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6957
Mailing Address - Country:US
Mailing Address - Phone:865-813-1009
Mailing Address - Fax:865-482-4036
Practice Address - Street 1:800 OAK RIDGE TPKE
Practice Address - Street 2:SUITE A-300
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6957
Practice Address - Country:US
Practice Address - Phone:865-813-1009
Practice Address - Fax:865-482-4036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000013542363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNAPN0000013542OtherCERTIFIED ADVANCED PRACTICE NURSE LICENSE
TN208001120OtherANCC CERTIFICATE FOR FNP