Basic Information
| Provider Information | |||||||||
| NPI: | 1528113602 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIPSON | ||||||||
| FirstName: | TANJALA | ||||||||
| MiddleName: | TRINETTE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 POPLAR AVE BLDG 2 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381054607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012875674 | ||||||||
| FaxNumber: | 9012876804 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 N DUNLAP ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381054625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012877337 | ||||||||
| FaxNumber: | 9013875143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 04/14/2018 | ||||||||
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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 | 2080P0008X | 54122 | TN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | TN | MEDICAID |