Basic Information
| Provider Information | |||||||||
| NPI: | 1013052463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREYTAG | ||||||||
| FirstName: | ADDIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 308 | ||||||||
| Address2: | |||||||||
| City: | WARTBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378870368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233465566 | ||||||||
| FaxNumber: | 4233465631 | ||||||||
| Practice Location | |||||||||
| Address1: | 1236 KNOXVILLE HWY | ||||||||
| Address2: | |||||||||
| City: | WARTBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233465566 | ||||||||
| FaxNumber: | 4233465631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 04/10/2013 | ||||||||
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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 | 363LF0000X | RN23757 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3341447 | 05 | TN | MEDICAID | RN23757 | 01 | TN | LICEASE | OTHER | 4031545 | 01 | TN | BCBS | OTHER | MF0441751 | 01 | TN | DEA | OTHER |