Healthcare Provider Details

I. General information

NPI: 1154353092
Provider Name (Legal Business Name): MEMORIAL CLINIC P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 04/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E COMMERCE ST
WAVERLY TN
37185-1629
US

IV. Provider business mailing address

203 E COMMERCE ST
WAVERLY TN
37185-1629
US

V. Phone/Fax

Practice location:
  • Phone: 931-296-5833
  • Fax: 931-296-7388
Mailing address:
  • Phone: 931-296-5833
  • Fax: 931-296-7388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BONNIE SUE JUDD
Title or Position: OWNER
Credential: APN
Phone: 931-296-5833