Provider Demographics
NPI:1770844110
Name:COMMUNITY WELLNESS CLINIC INC.
Entity Type:Organization
Organization Name:COMMUNITY WELLNESS CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:615-563-7515
Mailing Address - Street 1:322 S MCCRARY ST
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:TN
Mailing Address - Zip Code:37190-1441
Mailing Address - Country:US
Mailing Address - Phone:615-563-7515
Mailing Address - Fax:615-563-7393
Practice Address - Street 1:322 S MCCRARY ST
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:TN
Practice Address - Zip Code:37190-1441
Practice Address - Country:US
Practice Address - Phone:615-563-7515
Practice Address - Fax:615-563-7393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15595363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty