Provider Demographics
NPI:1205318557
Name:BANYAN FAMILY NIGHT CLINIC, LLC
Entity type:Organization
Organization Name:BANYAN FAMILY NIGHT CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WINGO-SALMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, FNP
Authorized Official - Phone:423-284-3157
Mailing Address - Street 1:276B JAMES ASBURY DR NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-2984
Mailing Address - Country:US
Mailing Address - Phone:423-464-5776
Mailing Address - Fax:423-464-5665
Practice Address - Street 1:276B JAMES ASBURY DR NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-2984
Practice Address - Country:US
Practice Address - Phone:423-464-5776
Practice Address - Fax:423-464-5665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty