Organization
EAST TENNESSEE STATE UNIVERSITY
Active
Other names
Student University Health Services
Organization subpart
No
Provider details
NPI number
Authorized official
BETTY J KING (ACTING CHIEF FINANCIAL OFFICER)
(423) 439-4414
Entity
Organization
Contact information
Practice address
365 STOUT DRIVE, NICKS HALL RM 160, JOHNSON CITY, TN 37614-6500
(423) 439-4225
(423) 439-4560
Mailing address
365 STOUT DRIVE BOX 70403, JOHNSON CITY, TN 37614-1703
(423) 439-4515
(423) 439-5780
Taxonomy
Speciality
Code
Description
License number
State
261QM1300X
Multi-Specialty Clinic/Center
Primary
—
—
363LP2300X
Primary Care Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3709292
—
TN
Enumeration date
08/25/2006
Last updated
09/22/2017
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