| NPI | 1972141620 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CASEY MICHELLE MARCOM Office Administrator 731-300-7755 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family |
| Enumeration Date | 2019-12-12 |
| Last Update Date | 2019-12-12 |