Provider Demographics
NPI:1619731247
Name:MEREDITH, EMILY THERESA
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:THERESA
Last Name:MEREDITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 TABAGO LN
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-8051
Mailing Address - Country:US
Mailing Address - Phone:270-534-1176
Mailing Address - Fax:
Practice Address - Street 1:379 COBALT BAY LOOP APT 102
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-9070
Practice Address - Country:US
Practice Address - Phone:270-534-1176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3879152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist