Healthcare Provider Details

I. General information

NPI: 1982916896
Provider Name (Legal Business Name): AUDREY B.R. VANWYLEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS AUDREY B RICHARDSON

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2861 BROAD AVE
MEMPHIS TN
38112-2903
US

IV. Provider business mailing address

2595 CENTRAL AVE
MEMPHIS TN
38104-5905
US

V. Phone/Fax

Practice location:
  • Phone: 901-701-2520
  • Fax: 901-325-6469
Mailing address:
  • Phone: 901-260-8500
  • Fax: 901-260-8598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301096247
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number50473
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: