Basic Information
| Provider Information | |||||||||
| NPI: | 1962027102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOBERLEIN | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | SMITH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN, BSN, PMHNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | SARAH | ||||||||
| OtherMiddleName: | JESSICA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN, BSN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2347 JONES BEND RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377775213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659709800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2347 JONES BEND RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377775233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659709800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2020 | ||||||||
| LastUpdateDate: | 08/05/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 27661 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | Q058457 | 05 | TN | MEDICAID |