Provider Demographics
NPI:1063929289
Name:MITCHELL, WENDY (FNP)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 DOVER RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-4157
Mailing Address - Country:US
Mailing Address - Phone:931-552-6722
Mailing Address - Fax:931-552-6979
Practice Address - Street 1:305 DOVER RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042
Practice Address - Country:US
Practice Address - Phone:931-552-6722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000210926163W00000X
TNF10170142363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100529340Medicaid