Basic Information
| Provider Information | |||||||||
| NPI: | 1457789380 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAUGHT | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 E REELFOOT AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382616049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315070272 | ||||||||
| FaxNumber: | 7315070273 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 CARL PERKINS PKWY | ||||||||
| Address2: | |||||||||
| City: | TIPTONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380791678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312536690 | ||||||||
| FaxNumber: | 7312536692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2013 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APN0000017625 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | Q005152 | 05 | TN | MEDICAID |