Provider Demographics
NPI:1265741979
Name:MURDOCK, MARY W (MSN, CNM)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:W
Last Name:MURDOCK
Suffix:
Gender:F
Credentials:MSN, CNM
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:WOMACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:979 E 3RD ST
Mailing Address - Street 2:SUITE A-440
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2136
Mailing Address - Country:US
Mailing Address - Phone:423-266-6116
Mailing Address - Fax:
Practice Address - Street 1:979 E 3RD ST
Practice Address - Street 2:SUITE A-440
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2136
Practice Address - Country:US
Practice Address - Phone:423-266-6116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5993367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1522662Medicaid
TN1522662Medicaid