Provider Demographics
NPI:1710489067
Name:SAGEN, MARY GWENDOLYN (PNP-PC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GWENDOLYN
Last Name:SAGEN
Suffix:
Gender:F
Credentials:PNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 DALE AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37204-4126
Mailing Address - Country:US
Mailing Address - Phone:601-754-6279
Mailing Address - Fax:
Practice Address - Street 1:4720 TRADERS WAY
Practice Address - Street 2:
Practice Address - City:THOMPSONS STATION
Practice Address - State:TN
Practice Address - Zip Code:37179-5429
Practice Address - Country:US
Practice Address - Phone:615-302-1279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23810363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics