Healthcare Provider Details

I. General information

NPI: 1689643074
Provider Name (Legal Business Name): MARY ELIZABETH WRIGHT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ELIZABETH WELLS FNP

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 04/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20471 AZEN RD
DAMASCUS VA
24236-4141
US

IV. Provider business mailing address

602 W MORGAN AVE SUITE 3
PENNINGTON GAP VA
24277-2036
US

V. Phone/Fax

Practice location:
  • Phone: 276-388-3411
  • Fax: 276-388-3732
Mailing address:
  • Phone: 276-546-5310
  • Fax: 276-546-5469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024135977
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: