Healthcare Provider Details

I. General information

NPI: 1851164560
Provider Name (Legal Business Name): WADDELL CLINIC PRIMARY CARE & AESTHETICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2023
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9785 HWY 79 S
HENRY TN
38231
US

IV. Provider business mailing address

9785 HIGHWAY 79 S
HENRY TN
38231-3613
US

V. Phone/Fax

Practice location:
  • Phone: 731-423-1450
  • Fax: 731-423-1000
Mailing address:
  • Phone: 731-243-1450
  • Fax: 731-243-1000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DONNA WADDELL
Title or Position: OWNER
Credential: NP-C
Phone: 731-415-8277