Healthcare Provider Details

I. General information

NPI: 1760767016
Provider Name (Legal Business Name): MODEANNA LEIGH WADE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

899 HIGHWAY 51 S
COVINGTON TN
38019-2568
US

IV. Provider business mailing address

2693 UNION AVENUE EXT STE 100
MEMPHIS TN
38112-4403
US

V. Phone/Fax

Practice location:
  • Phone: 901-244-4646
  • Fax: 901-244-4647
Mailing address:
  • Phone: 901-726-0843
  • Fax: 901-708-2699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0000016204
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: