Provider Demographics
NPI:1487952917
Name:OLIVER, MARY KATHRYN (CPNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHRYN
Last Name:OLIVER
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 GLEAVES ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-2176
Mailing Address - Country:US
Mailing Address - Phone:615-851-7865
Mailing Address - Fax:615-851-7866
Practice Address - Street 1:200 GLEAVES ST
Practice Address - Street 2:SUITE A
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-2176
Practice Address - Country:US
Practice Address - Phone:615-851-7865
Practice Address - Fax:615-851-7866
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15587363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1524067Medicaid