Provider Demographics
NPI:1881934610
Name:HART, WANDA J
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:J
Last Name:HART
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 1:316 MYSTIC HILL DR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-1252
Mailing Address - Country:US
Mailing Address - Phone:615-310-7377
Mailing Address - Fax:
Practice Address - Street 1:105B MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-1525
Practice Address - Country:US
Practice Address - Phone:615-766-8207
Practice Address - Fax:615-766-8217
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-14
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17213363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicaid