Provider Demographics
NPI:1710953195
Name:WADE, MARY LYNETTE (RN, CFNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LYNETTE
Last Name:WADE
Suffix:
Gender:F
Credentials:RN, CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 PERCY RD
Mailing Address - Street 2:
Mailing Address - City:FARMERVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71241-8161
Mailing Address - Country:US
Mailing Address - Phone:318-368-3560
Mailing Address - Fax:
Practice Address - Street 1:1025 MARION HWY
Practice Address - Street 2:
Practice Address - City:FARMERVILLE
Practice Address - State:LA
Practice Address - Zip Code:71241-9314
Practice Address - Country:US
Practice Address - Phone:318-368-9745
Practice Address - Fax:318-368-0072
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN035495 3693363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA110484125BOtherBLUE CROSS BLUE SHIELD
LA1433179Medicaid
LA1433179Medicaid
LA4B645F780Medicare Oscar/Certification