Provider Demographics
NPI:1134769151
Name:WIDELOCK, EMILY LYNN (PA-C)
Entity type:Individual
Prefix:MISS
First Name:EMILY
Middle Name:LYNN
Last Name:WIDELOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-5044
Mailing Address - Country:US
Mailing Address - Phone:615-519-5213
Mailing Address - Fax:
Practice Address - Street 1:3443 DICKERSON PIKE STE 190
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37207-2533
Practice Address - Country:US
Practice Address - Phone:615-860-1580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3960363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant