=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225580046
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WADE CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2016
-----------------------------------------------------
Last Update Date | 10/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206 E TAYLOR AVE
-----------------------------------------------------
City | CALHOUN CITY
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-628-3838
-----------------------------------------------------
Fax | 662-628-3800
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1452
-----------------------------------------------------
City | CALHOUN CITY
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38916-1452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-628-3838
-----------------------------------------------------
Fax | 662-628-3800
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | JENNIFER E WADE
-----------------------------------------------------
Credential | FNP-BC
-----------------------------------------------------
Telephone | 662-628-3838
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------