Provider Demographics
NPI:1649259367
Name:TENNESEE DEPARTMENT OF HEALTH
Entity type:Organization
Organization Name:TENNESEE DEPARTMENT OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-650-7053
Mailing Address - Street 1:1008 RAMBLING BROOK RD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37218-3608
Mailing Address - Country:US
Mailing Address - Phone:615-299-0750
Mailing Address - Fax:615-299-0086
Practice Address - Street 1:330 PAGEANT LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-3854
Practice Address - Country:US
Practice Address - Phone:931-648-7280
Practice Address - Fax:931-648-7299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS 4582251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare