Provider Demographics
NPI:1760767016
Name:WADE, MODEANNA LEIGH (APRN)
Entity Type:Individual
Prefix:
First Name:MODEANNA
Middle Name:LEIGH
Last Name:WADE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S MUNFORD ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38019-2527
Mailing Address - Country:US
Mailing Address - Phone:901-244-4646
Mailing Address - Fax:901-244-4647
Practice Address - Street 1:899 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-2568
Practice Address - Country:US
Practice Address - Phone:901-244-4646
Practice Address - Fax:901-244-4647
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000016204363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily