Basic Information
| Provider Information | |||||||||
| NPI: | 1588746978 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLENWATER | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | PATTERSON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD,CNSD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PATTERSON | ||||||||
| OtherFirstName: | CAROLYN | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | RD, CNSD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 175 MOORE RD | ||||||||
| Address2: | |||||||||
| City: | JONESBOROUGH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376593856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237537211 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | JAMES H. QUILLEN/VAMC | ||||||||
| Address2: | CORNER OF SIDNEY AND LAMONT | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239792928 | ||||||||
| FaxNumber: | 4239793402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 133V00000X | 372037 | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.