Basic Information
| Provider Information | |||||||||
| NPI: | 1487716890 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHELBYVILLE HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WARTRACE FAMILY PRACTICE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 403621 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303843621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313890600 | ||||||||
| FaxNumber: | 9313896781 | ||||||||
| Practice Location | |||||||||
| Address1: | 507 BLACKMAN BLVD W | ||||||||
| Address2: | |||||||||
| City: | WARTRACE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371832210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313890600 | ||||||||
| FaxNumber: | 9313896781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOMBARDI-MOUNT | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 9313890600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHELBYVILLE HOSPITAL CORPORATION | ||||||||
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| AuthorizedOfficialCredential: | CFNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.