Basic Information
| Provider Information | |||||||||
| NPI: | 1407825805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALDROP | ||||||||
| FirstName: | ALICE | ||||||||
| MiddleName: | JEANETTE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 400 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383020400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314238697 | ||||||||
| FaxNumber: | 7314225743 | ||||||||
| Practice Location | |||||||||
| Address1: | 2863 HIGHWAY 45 BYP | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383053618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316641375 | ||||||||
| FaxNumber: | 7316641378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 11/29/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN42624 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | APN5345 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3902911 | 05 | TN | MEDICAID |