Provider Demographics
NPI:1740565282
Name:KEAGLE, WANDA FAYE (FNP)
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:FAYE
Last Name:KEAGLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:WANDA
Other - Middle Name:FAYE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:586 S JEFFERSON AVE STE L
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4637
Mailing Address - Country:US
Mailing Address - Phone:931-854-0050
Mailing Address - Fax:931-854-0411
Practice Address - Street 1:586 S JEFFERSON AVE STE L
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4637
Practice Address - Country:US
Practice Address - Phone:931-854-0050
Practice Address - Fax:931-854-0411
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16167363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily