1619498672 NPI number — FEARFULLY AND WONDERFULLY MADE OBGYN PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619498672 NPI number — FEARFULLY AND WONDERFULLY MADE OBGYN PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FEARFULLY AND WONDERFULLY MADE OBGYN PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619498672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2217
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37409-0217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-498-2300
Provider Business Mailing Address Fax Number:
423-498-2301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4012 WEST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37410-1594
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-498-2300
Provider Business Practice Location Address Fax Number:
423-498-2301
Provider Enumeration Date:
06/29/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SANDERS
Authorized Official First Name:
MARY
Authorized Official Middle Name:
ANNA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
423-498-2300

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com