Healthcare Provider Details

I. General information

NPI: 1316764145
Provider Name (Legal Business Name): MARY WISE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY VU MARY WISE

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

848 ADAMS AVE
MEMPHIS TN
38103-2816
US

IV. Provider business mailing address

12551 GOLDEN BELL DR N
ARLINGTON TN
38002-5147
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-5437
  • Fax:
Mailing address:
  • Phone: 901-283-3657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number151733
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: