Provider Demographics
NPI:1962861310
Name:ATOKA IDAVILLE FAMILY HEALTH, INC
Entity Type:Organization
Organization Name:ATOKA IDAVILLE FAMILY HEALTH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:VANDERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:901-837-0701
Mailing Address - Street 1:5847 ATOKA IDAVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:TN
Mailing Address - Zip Code:38011-7066
Mailing Address - Country:US
Mailing Address - Phone:901-837-0701
Mailing Address - Fax:901-837-0703
Practice Address - Street 1:5847 ATOKA IDAVILLE RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:TN
Practice Address - Zip Code:38011-7066
Practice Address - Country:US
Practice Address - Phone:901-304-8709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-13
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13123261QP2300X
TN2007009643363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3703407Medicaid