Basic Information
| Provider Information | |||||||||
| NPI: | 1710953195 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WADE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | LYNETTE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | RN, CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 PERCY RD | ||||||||
| Address2: | |||||||||
| City: | FARMERVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712418161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183683560 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1025 MARION HWY | ||||||||
| Address2: | |||||||||
| City: | FARMERVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712419314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183689745 | ||||||||
| FaxNumber: | 3183680072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 12/23/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN035495 3693 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 110484125B | 01 | LA | BLUE CROSS BLUE SHIELD | OTHER | 1433179 | 05 | LA | MEDICAID |