Form Ph-3619 Health Related Boards Name And Address Change Request
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Health Related Boards Name and Address Change Request
You are required to notify the board within thirty (30) days of changing your name and/or address. If you are changing your name, you
must submit a copy of the legal document that changes your name (i.e. marriage certificate, divorce decree or court order). Licensee’s
mailing and practice addresses are available to the public. There are several ways to change your name and/or address:
1.
Print, complete, and mail the form to:
Board of (specify the name of your board)
665 Mainstream Drive
Nashville, TN 37243
2.
Using the form as your guide, e-mail the information to us at tn.health@tn.gov
3.
You can change your address online at https://apps.tn.gov/hlrs/begin.jsp. You cannot change your name online.
4.
Print, complete, and fax the form to the fax number that applies to your profession:
615-741-7899 for:
Registered Nurse
Licensed Practical Nurse
Advanced Practice Nurse
615-253-4484 for:
Medical Doctor
Osteopathic X-Ray Operator
Medical X-Ray Operator
Physician Assistant
Acupuncture
Midwifery
Polysomnography
ADS
Orthopedic Physicians Assistant
Radiology Assistant
Clinical Perfusionist
Osteopathic Physician
Genetic Counselor
615-532-5369 for:
Clinical Pastoral Therapist
Pedorthist
Dispensing Optician
Podiatrist
Advanced Practice Social Worker
Dispensing Optician Apprentice
Podiatric X-Ray Operator
Alcohol and Drug Abuse Counselor
Hearing Instrument Specialists
Prosthetist
Audiologist
Hearing Instrument - Apprentice
Psychologist
Baccalaureate Social Worker
Licensed Marital and Family Therapists
Psychological Examiner
Certified Marital and Family Therapist
Licensed Masters Social Worker
Psychological Assistant
Certified Professional Counselor
Licensed Professional Counselors
Speech Language Pathologist
Chiropractic Physician
Optometrist
Speech Pathologist Assistant
Chiropractic Therapy Assistant
Orthotist
Chiropractic X-Ray Technologist
615-253-8724 for:
Electrology School
Occupational Therapy Assistant
Licensed Certified Respiratory Therapist
Physical Therapist
Athletic Trainer
Licensed Registered Respiratory Therapist
Physical Therapy Assistant
Certified Respiratory Care Assistant
Nursing Home Administrator
Reflexologist
Dietitians and Nutritionist
Occupational Therapist
Electrologist
615-770-7444 for:
Dental Hygienist
Dentist
Dental Assistant
615-532-5164 for:
Massage Therapist
Veterinarian
Certified Animal Chemical Capture Technician
Veterinary Medical Technician
Certified Animal Euthanasia Technician
615-741-2722 for:
Pharmacy Technician
Medical Service Representative
Pharmacist
615-248-3601 for:
Certified Nurse Aide
615-253-8724 for:
Medical Laboratory Personnel
PH-3619
RDA-1786
Rev. 1/09
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Parent category: Legal