Basic Information
| Provider Information | |||||||||
| NPI: | 1588698732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAWKINS | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 70403 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376141703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394078 | ||||||||
| FaxNumber: | 4234394060 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 S SHADY ST | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376832021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237271150 | ||||||||
| FaxNumber: | 4237271152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 02/01/2008 | ||||||||
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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 | APN05714 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3348482 | 05 | TN | MEDICAID | 4032280 | 01 | TN | BLUECROSSBLUESHIELD | OTHER | TN01G3 | 01 | TN | JOHN DEERE | OTHER |