Provider Demographics
NPI:1023374279
Name:MOORE, PHYLLIS P (DNP,FNP-BC)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:P
Last Name:MOORE
Suffix:
Gender:F
Credentials:DNP,FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FRIENDSHIP
Mailing Address - State:TN
Mailing Address - Zip Code:38034-1999
Mailing Address - Country:US
Mailing Address - Phone:731-677-3400
Mailing Address - Fax:731-677-3402
Practice Address - Street 1:600 MAIN ST
Practice Address - Street 2:
Practice Address - City:FRIENDSHIP
Practice Address - State:TN
Practice Address - Zip Code:38034-1999
Practice Address - Country:US
Practice Address - Phone:731-677-3400
Practice Address - Fax:731-677-3402
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000016606363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ021117Medicaid