Basic Information
| Provider Information | |||||||||
| NPI: | 1811161813 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WADDELL | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ANP, GCNS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHULL | ||||||||
| OtherFirstName: | BEVERLY | ||||||||
| OtherMiddleName: | JANE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ANP, GCNS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376620009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238572066 | ||||||||
| FaxNumber: | 4238572070 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 W STONE DR | ||||||||
| Address2: | STE 5C | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233787645 | ||||||||
| FaxNumber: | 4233923863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2008 | ||||||||
| LastUpdateDate: | 11/18/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SG0600X | 13413 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology | 163W00000X | RN129155 | TN | N | Nursing Service Providers | Registered Nurse | 363LA2200X | APN13413 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1510164 | 05 | TN | MEDICAID |