Healthcare Provider Details

I. General information

NPI: 1730759028
Provider Name (Legal Business Name): HALEY DEROJAS WIGGINS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

739 PRESIDENT PL STE 110
SMYRNA TN
37167-6845
US

IV. Provider business mailing address

5077 CITATION DR
MT JULIET TN
37122-3595
US

V. Phone/Fax

Practice location:
  • Phone: 615-625-7780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN0000027199
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAPN0000027199
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: