Basic Information
| Provider Information | |||||||||
| NPI: | 1033176532 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IRVIN | ||||||||
| FirstName: | JOANNE | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DIFFLEY-CANNIFF | ||||||||
| OtherFirstName: | JOANNE | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 850 | ||||||||
| Address2: | ATTN WANDA BROWN CREDENTIALING | ||||||||
| City: | ROGERSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378570850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232729163 | ||||||||
| FaxNumber: | 4239216920 | ||||||||
| Practice Location | |||||||||
| Address1: | 4966 HIGHWAY 11W | ||||||||
| Address2: | HAWKINS MEDICAL CENTER | ||||||||
| City: | ROGERSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232725600 | ||||||||
| FaxNumber: | 4232721428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 12/27/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 11979 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3643282 | 05 | TN | MEDICAID | 4124843 | 01 | TN | BCBST | OTHER |