Healthcare Provider Details

I. General information

NPI: 1689630170
Provider Name (Legal Business Name): REBECCA LYNN WALDON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 JEFFERSON AVE
MEMPHIS TN
38104-2127
US

IV. Provider business mailing address

1960 N PARKWAY #109
MEMPHIS TN
38112-5002
US

V. Phone/Fax

Practice location:
  • Phone: 901-523-8990
  • Fax:
Mailing address:
  • Phone: 901-276-5784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0000005904
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPN0000005904
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: