Healthcare Provider Details

I. General information

NPI: 1962796888
Provider Name (Legal Business Name): WAVERLY PEDIATRIC AND ADULT CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 06/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 W MAIN ST
WAVERLY TN
37185-1447
US

IV. Provider business mailing address

1034 W MAIN ST
WAVERLY TN
37185-1447
US

V. Phone/Fax

Practice location:
  • Phone: 931-296-7000
  • Fax: 931-296-7231
Mailing address:
  • Phone: 931-296-7000
  • Fax: 931-296-7231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMD8719
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberAPN0000015777
License Number StateTN

VIII. Authorized Official

Name: DR. MARY ANGELA SKELTON
Title or Position: OWNER
Credential: M.D.
Phone: 931-296-7000