Healthcare Provider Details

I. General information

NPI: 1497740674
Provider Name (Legal Business Name): MARY BEDWELL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1362 MISSISSIPPI BLVD
MEMPHIS TN
38106-4709
US

IV. Provider business mailing address

877 JEFFERSON AVE 5TH FLOOR ADAMS PAVILION
MEMPHIS TN
38103-2807
US

V. Phone/Fax

Practice location:
  • Phone: 901-515-5700
  • Fax: 901-942-2002
Mailing address:
  • Phone: 901-515-5700
  • Fax: 901-942-2002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6199
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: