Provider Demographics
NPI:1497740674
Name:BEDWELL, MARY (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BEDWELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 JEFFERSON AVE
Mailing Address - Street 2:5TH FLOOR ADAMS PAVILION
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2807
Mailing Address - Country:US
Mailing Address - Phone:901-515-5700
Mailing Address - Fax:901-942-2002
Practice Address - Street 1:1362 MISSISSIPPI BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38106-4709
Practice Address - Country:US
Practice Address - Phone:901-515-5700
Practice Address - Fax:901-942-2002
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6199363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3903771Medicaid
TN3903771Medicaid
TNS84166Medicare UPIN