Provider Demographics
NPI:1487089322
Name:WADE, MELANIE LEIGH (MSN, NP)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:LEIGH
Last Name:WADE
Suffix:
Gender:F
Credentials:MSN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1167 SPRATLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-6205
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:426 E G ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-3224
Practice Address - Country:US
Practice Address - Phone:423-547-5950
Practice Address - Fax:423-467-3644
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171094363L00000X
TN17925363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10350I7263Medicare PIN