Basic Information
| Provider Information | |||||||||
| NPI: | 1982826004 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOTTS | ||||||||
| FirstName: | DARA | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 WINWOOD DR STE 205 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370871399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1544444126 | ||||||||
| FaxNumber: | 8557852890 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 WINWOOD DR STE 205 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370871399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154444126 | ||||||||
| FaxNumber: | 8557852890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 12/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 57268 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | Q012339 | 05 | TN | MEDICAID |