Provider Demographics
NPI:1730550567
Name:WILBURN, TIMOTHY (CPHT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:WILBURN
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 CORY DRIVE
Mailing Address - Street 2:APT 324
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37771-8577
Mailing Address - Country:US
Mailing Address - Phone:423-519-0117
Mailing Address - Fax:865-986-1542
Practice Address - Street 1:721 HIGHWAY 321 N
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37771-5003
Practice Address - Country:US
Practice Address - Phone:865-988-0000
Practice Address - Fax:865-986-1542
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41357247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other