Provider Demographics
NPI:1932575958
Name:TANKERSLEY, CALLIE E (NP)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:E
Last Name:TANKERSLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:105 W STONE DR STE 1F
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3365
Practice Address - Country:US
Practice Address - Phone:423-230-2420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN169201163W00000X
VA0024173100363LF0000X
TN20506363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVJ741B288Medicare PIN
TN10350I8215Medicare PIN