Basic Information
| Provider Information | |||||||||
| NPI: | 1417385212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDERMAN | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LANDERMAN | ||||||||
| OtherFirstName: | CAROL | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1327 | ||||||||
| Address2: | 1330 CEDAR LN BLDG B SUITE 900 | ||||||||
| City: | TULLAHOMA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373881327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314552674 | ||||||||
| FaxNumber: | 9314558983 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 CEDAR LN STE 900 | ||||||||
| Address2: | |||||||||
| City: | TULLAHOMA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373882286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314552674 | ||||||||
| FaxNumber: | 9314558983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2013 | ||||||||
| LastUpdateDate: | 09/18/2014 | ||||||||
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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 | APN0000018032 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | Q004882 | 05 | TN | MEDICAID |