Provider Demographics
NPI:1265144943
Name:WASHAM, MALEAH VICTORIA
Entity type:Individual
Prefix:
First Name:MALEAH
Middle Name:VICTORIA
Last Name:WASHAM
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 1:1114 FAIRGROUNDS CT
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-2657
Mailing Address - Country:US
Mailing Address - Phone:865-919-4783
Mailing Address - Fax:865-674-4422
Practice Address - Street 1:1114 FAIRGROUNDS CT
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-2657
Practice Address - Country:US
Practice Address - Phone:865-919-4783
Practice Address - Fax:865-674-4422
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN246088163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice