Healthcare Provider Details

I. General information

NPI: 1720095086
Provider Name (Legal Business Name): MARY ANN LIGHT APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 06/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

796 RIDGEWAY AVE
SIGNAL MOUNTAIN TN
37377-3067
US

IV. Provider business mailing address

PO BOX 772
WOONSOCKET RI
02895-0784
US

V. Phone/Fax

Practice location:
  • Phone: 423-886-3269
  • Fax:
Mailing address:
  • Phone: 401-770-5779
  • Fax: 401-652-9787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-052430
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12784
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: