Basic Information
| Provider Information | |||||||||
| NPI: | 1477044717 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOTTS DIABETES & ENDOCRINOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 WINWOOD DR STE 205 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370871399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154444126 | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 WINWOOD DR STE 205 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370871399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154444126 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2018 | ||||||||
| LastUpdateDate: | 02/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | BOTTS | ||||||||
| AuthorizedOfficialFirstName: | DARA | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6154444126 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.