Basic Information
| Provider Information | |||||||||
| NPI: | 1417958778 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROFFITT | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 E SPRINGBROOK DR | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376011761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237945550 | ||||||||
| FaxNumber: | 4237945867 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 MED TECH PKWY | ||||||||
| Address2: | STE 280 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237945500 | ||||||||
| FaxNumber: | 4239281174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 04/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 39839 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3329984 | 05 | TN | MEDICAID |