Basic Information
| Provider Information | |||||||||
| NPI: | 1215371299 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYNATT | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 TECH CENTER DR | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379122747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656379711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 ARTHUR ST | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379216405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655238695 | ||||||||
| FaxNumber: | 8655236827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2013 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | RN0000185583 | TN | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | 17552 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 0000017552 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | Q000888 | 05 | TN | MEDICAID |