Provider Demographics
NPI:1487101036
Name:MANTOOTH, PATRICIA (NP)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:MANTOOTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5141 VIRGINIA WAY
Mailing Address - Street 2:SUITE 390
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7572
Mailing Address - Country:US
Mailing Address - Phone:615-988-1571
Mailing Address - Fax:615-988-1635
Practice Address - Street 1:756 COSBY HWY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-3455
Practice Address - Country:US
Practice Address - Phone:423-237-6546
Practice Address - Fax:423-237-6579
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21587363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily