Provider Demographics
NPI:1558904433
Name:COLLINS SQUIREWELL, WENDY RENEE
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:RENEE
Last Name:COLLINS SQUIREWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SAVANNAH COURT EAST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172
Mailing Address - Country:US
Mailing Address - Phone:615-579-0819
Mailing Address - Fax:
Practice Address - Street 1:612 W DUE WEST AVE # G100
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-4402
Practice Address - Country:US
Practice Address - Phone:615-258-1990
Practice Address - Fax:615-258-1992
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN079013609172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver