Basic Information
| Provider Information | |||||||||
| NPI: | 1649898933 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRENT | ||||||||
| FirstName: | MATTIE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEE | ||||||||
| OtherFirstName: | MATTIE | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 850 | ||||||||
| Address2: | |||||||||
| City: | ROGERSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378570850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239216975 | ||||||||
| FaxNumber: | 4239216920 | ||||||||
| Practice Location | |||||||||
| Address1: | 4307 HIGHWAY 66 S | ||||||||
| Address2: | |||||||||
| City: | ROGERSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378573155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239211600 | ||||||||
| FaxNumber: | 4239211675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2020 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0000230472 | TN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 28957 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.