Provider Demographics
NPI:1194796557
Name:MINNICK, MARY JANE (ACNP)
Entity type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:MINNICK
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:MARY JANE
Other - Middle Name:
Other - Last Name:LEHTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1915 WHITE AVE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-2300
Mailing Address - Country:US
Mailing Address - Phone:865-541-1720
Mailing Address - Fax:865-541-1747
Practice Address - Street 1:1915 WHITE AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2300
Practice Address - Country:US
Practice Address - Phone:865-541-1720
Practice Address - Fax:865-541-1747
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11823363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner