Provider Demographics
NPI:1790101558
Name:SORAH, CELESTE Y
Entity Type:Individual
Prefix:
First Name:CELESTE
Middle Name:Y
Last Name:SORAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:271 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7455
Practice Address - Country:US
Practice Address - Phone:423-968-2311
Practice Address - Fax:423-968-2109
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171583363LF0000X
TN19149363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10350I1336Medicare PIN
VAVVD887BMedicare PIN