Basic Information
| Provider Information | |||||||||
| NPI: | 1194993345 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEIL | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | PROVINCE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ANP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PROVINCE | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ANP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 92 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379010092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8658620998 | ||||||||
| FaxNumber: | 8655441861 | ||||||||
| Practice Location | |||||||||
| Address1: | 7551 DANNAHER LANE | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378494026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656379330 | ||||||||
| FaxNumber: | 8655126748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2008 | ||||||||
| LastUpdateDate: | 07/06/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 13492 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1530023 | 05 | TN | MEDICAID | 6051712 | 01 | TN | BCBS | OTHER | P01548991 | 01 | TN | MEDICARE RR | OTHER |