Provider Demographics
NPI:1154809796
Name:DALE, AVERY LYNETTE (PMHNP)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:LYNETTE
Last Name:DALE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 GERMANTOWN CT STE 402
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-4275
Mailing Address - Country:US
Mailing Address - Phone:901-752-4900
Mailing Address - Fax:901-752-4902
Practice Address - Street 1:65 GERMANTOWN CT STE 402
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-4275
Practice Address - Country:US
Practice Address - Phone:901-752-4900
Practice Address - Fax:901-752-4902
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN118022163WP0808X
TN24777363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN118022OtherNURSING LICENSE
TN24777OtherADVANCE PRACTICE REGISTERED NURSE