Provider Demographics
NPI:1134689920
Name:WALL, MARY REBECCA (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:REBECCA
Last Name:WALL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 HOSPITAL DR STE A
Mailing Address - Street 2:
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-1649
Mailing Address - Country:US
Mailing Address - Phone:731-352-7907
Mailing Address - Fax:731-352-4459
Practice Address - Street 1:136 S WILSON ST
Practice Address - Street 2:
Practice Address - City:DRESDEN
Practice Address - State:TN
Practice Address - Zip Code:38225-1133
Practice Address - Country:US
Practice Address - Phone:731-364-4900
Practice Address - Fax:731-352-4459
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000025488363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3380640Medicaid