MEDICARE: KECIA A WISDOM APN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	RN0000074758	TN

General Provider Information

NPI Number	:	1215945076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KECIA A WISDOM APN

Provider Business Mailing Address
First Line	:	PO BOX 520
Second Line	:
City	:	WEST PADUCAH
State	:	KY
Zip	:	42086-0520
Country	:	US
Telephone Number	:	270-744-0404
Fax Number	:	270-744-0606

Provider Business Practice Location Address
First Line	:	301 WOLVERINE TRL
Second Line	:	SUITE 100
City	:	SMYRNA
State	:	TN
Zip	:	37167-5656
Country	:	US
Telephone Number	:	615-459-6700
Fax Number	:	615-459-0068

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	02/20/2008

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