Basic Information
| Provider Information | |||||||||
| NPI: | 1114255817 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AWAKENING MINDFUL POSSIBILITIES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 KENSINGTON PL | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384018885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313800677 | ||||||||
| FaxNumber: | 9313800677 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 KENSINGTON PL | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384018885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313800677 | ||||||||
| FaxNumber: | 9313800677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2009 | ||||||||
| LastUpdateDate: | 11/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | TALLMAN | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | MATTHEW | ||||||||
| AuthorizedOfficialTitleorPosition: | C.E.O./ PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 9313800677 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSN, RN, APN-BC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | APN0000014483 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.