Provider Demographics
NPI:1659309565
Name:FARIES, JANE E (NP)
Entity type:Individual
Prefix:MRS
First Name:JANE
Middle Name:E
Last Name:FARIES
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 1:999 EXECUTIVE PARK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4632
Mailing Address - Country:US
Mailing Address - Phone:423-224-3250
Mailing Address - Fax:423-224-3258
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3810
Practice Address - Country:US
Practice Address - Phone:423-224-5631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN5872363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3908886Medicaid
TNP00105054Medicare PIN
TN103I502949Medicare PIN
TN3908886Medicaid
TN3908886Medicare PIN