Provider Demographics
NPI:1831417658
Name:ELLEDGE, GARY NEWTON (MSN, NP-C)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:NEWTON
Last Name:ELLEDGE
Suffix:
Gender:M
Credentials:MSN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KIMBALL
Mailing Address - State:TN
Mailing Address - Zip Code:37347-5551
Mailing Address - Country:US
Mailing Address - Phone:423-837-6000
Mailing Address - Fax:
Practice Address - Street 1:1511 MAIN ST
Practice Address - Street 2:
Practice Address - City:KIMBALL
Practice Address - State:TN
Practice Address - Zip Code:37347-5551
Practice Address - Country:US
Practice Address - Phone:423-837-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000014743363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily