Provider Demographics
NPI:1811161813
Name:WADDELL, BEVERLY JANE (ANP, GCNS)
Entity type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:JANE
Last Name:WADDELL
Suffix:
Gender:F
Credentials:ANP, GCNS
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:JANE
Other - Last Name:SHULL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP, GCNS
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:105 W STONE DR
Practice Address - Street 2:STE 5C
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3365
Practice Address - Country:US
Practice Address - Phone:423-378-7645
Practice Address - Fax:423-392-3863
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13413364SG0600X
TNRN129155163W00000X
TNAPN13413363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1510164Medicaid
TN3341872Medicare UPIN
TN103I086169Medicare UPIN
TN1510164Medicaid