Basic Information
Provider Information | |||||||||
NPI: | 1689643074 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WRIGHT | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WELLS | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 602 W MORGAN AVE | ||||||||
Address2: | SUITE 3 | ||||||||
City: | PENNINGTON GAP | ||||||||
State: | VA | ||||||||
PostalCode: | 242772036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2765465310 | ||||||||
FaxNumber: | 2765465469 | ||||||||
Practice Location | |||||||||
Address1: | 20471 AZEN RD | ||||||||
Address2: |   | ||||||||
City: | DAMASCUS | ||||||||
State: | VA | ||||||||
PostalCode: | 242364141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2763883411 | ||||||||
FaxNumber: | 2763883732 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/16/2006 | ||||||||
LastUpdateDate: | 04/01/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024135977 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.