Basic Information
| Provider Information | |||||||||
| NPI: | 1487101036 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANTOOTH | ||||||||
| FirstName: | PATRICIA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5141 VIRGINIA WAY | ||||||||
| Address2: | SUITE 390 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159881571 | ||||||||
| FaxNumber: | 6159881635 | ||||||||
| Practice Location | |||||||||
| Address1: | 756 COSBY HWY | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378213455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232376546 | ||||||||
| FaxNumber: | 4232376579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2016 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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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 | 21587 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.