Basic Information
| Provider Information | |||||||||
| NPI: | 1316117013 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CHRISTY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4600 FORT HENRY DR | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376632617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243950 | ||||||||
| FaxNumber: | 4232243959 | ||||||||
| Practice Location | |||||||||
| Address1: | 378 MARKETPLACE DR STE 5 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232820751 | ||||||||
| FaxNumber: | 4232821577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2008 | ||||||||
| LastUpdateDate: | 04/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 13305 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1316117013 | 05 | VA | MEDICAID | 3341759 | 05 | TN | MEDICAID |