MEDICARE: MRS. RENEE LYNN WADE FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	200851	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	200851	OTHER	NC	NURSE PRACTITIONER LICENS
2	75732	OTHER	NC	NURSE PRACTITIONER REG #

General Provider Information

NPI Number	:	1508845413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RENEE LYNN WADE FNP

Provider Business Mailing Address
First Line	:	70 CRAPE MYRTLE DR
Second Line	:	SUITE 104
City	:	BENSON
State	:	NC
Zip	:	27504-8034
Country	:	US
Telephone Number	:	919-938-0260
Fax Number	:	919-938-0350

Provider Business Practice Location Address
First Line	:	70 CRAPE MYRTLE DR
Second Line	:	SUITE 104
City	:	BENSON
State	:	NC
Zip	:	27504-8034
Country	:	US
Telephone Number	:	919-938-0260
Fax Number	:	919-938-0350

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	02/10/2017

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