Provider Demographics
NPI:1336563204
Name:CUMBERLAND GAP MEDICAL
Entity Type:Organization
Organization Name:CUMBERLAND GAP MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:423-201-9799
Mailing Address - Street 1:502 W CENTRAL AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LA FOLLETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37766-3400
Mailing Address - Country:US
Mailing Address - Phone:423-201-9799
Mailing Address - Fax:423-437-8162
Practice Address - Street 1:502 W CENTRAL AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-3400
Practice Address - Country:US
Practice Address - Phone:423-201-9799
Practice Address - Fax:423-437-8162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000016605363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty