Provider Demographics
NPI:1437289220
Name:WETSELL, MARY K (PNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:K
Last Name:WETSELL
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1029 W MAIN ST
Mailing Address - Street 2:SUITE M
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-3351
Mailing Address - Country:US
Mailing Address - Phone:615-453-1252
Mailing Address - Fax:615-453-1286
Practice Address - Street 1:1029 W MAIN ST
Practice Address - Street 2:SUITE M
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-3351
Practice Address - Country:US
Practice Address - Phone:615-453-1252
Practice Address - Fax:615-453-1286
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN152241363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5441208Medicaid