Provider Demographics
NPI:1730776493
Name:FLOURNOY-WEST, DEEDRA L
Entity type:Individual
Prefix:
First Name:DEEDRA
Middle Name:L
Last Name:FLOURNOY-WEST
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 1:1811 DALTON ST
Mailing Address - Street 2:
Mailing Address - City:ALCOA
Mailing Address - State:TN
Mailing Address - Zip Code:37701-2335
Mailing Address - Country:US
Mailing Address - Phone:865-363-4845
Mailing Address - Fax:
Practice Address - Street 1:1811 DALTON ST
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701-2335
Practice Address - Country:US
Practice Address - Phone:186-536-3484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service