Basic Information
| Provider Information | |||||||||
| NPI: | 1326379751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELEONARDIS | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHYSICIAN ASSISTANT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PHYSICIAN ASSISTANT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1949 GUNBARREL RD | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374213188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234954345 | ||||||||
| FaxNumber: | 4234954934 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 CLINTON AVE | ||||||||
| Address2: | |||||||||
| City: | SPRING CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373814010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233652171 | ||||||||
| FaxNumber: | 4233655456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2010 | ||||||||
| LastUpdateDate: | 01/09/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1516780 | 05 | TN | MEDICAID | 1091133 | 01 | NCCPA | OTHER |