Healthcare Provider Details

I. General information

NPI: 1275887580
Provider Name (Legal Business Name): WELL CHILD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 NEW YORK ST
MEMPHIS TN
38104-5536
US

IV. Provider business mailing address

112 CABRIOLET CV
MARION AR
72364-2508
US

V. Phone/Fax

Practice location:
  • Phone: 901-728-5858
  • Fax: 901-274-5858
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17083
License Number StateTN

VIII. Authorized Official

Name: LAKISHA A MCDANIEL
Title or Position: FAMILY NURSE PRACTITIONER
Credential:
Phone: 870-739-8631