Provider Demographics
NPI:1982826004
Name:BOTTS, DARA W (FNP)
Entity Type:Individual
Prefix:
First Name:DARA
Middle Name:W
Last Name:BOTTS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 W BADDOUR PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-1510
Mailing Address - Country:US
Mailing Address - Phone:154-444-4126
Mailing Address - Fax:855-785-2890
Practice Address - Street 1:1420 W BADDOUR PKWY STE 200
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-1510
Practice Address - Country:US
Practice Address - Phone:154-444-4126
Practice Address - Fax:855-785-2890
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN57268363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ012339Medicaid
TNQ012339Medicaid
TN103I500592Medicare PIN
TN1035070I73Medicare PIN