Healthcare Provider Details

I. General information

NPI: 1629586375
Provider Name (Legal Business Name): WADE FAMILY MEDICINE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

899 HIGHWAY 51 S
COVINGTON TN
38019-2568
US

IV. Provider business mailing address

PO BOX 369
MILLINGTON TN
38083-0369
US

V. Phone/Fax

Practice location:
  • Phone: 901-244-4646
  • Fax: 901-244-4647
Mailing address:
  • Phone: 901-244-4648
  • Fax: 901-244-4647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number16204
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number16204
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MODEANNA LEIGH WADE
Title or Position: FNP
Credential:
Phone: 901-244-4648