Provider Demographics
NPI:1073523882
Name:DEVORE, AMY L (CNM)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:DEVORE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:877 JEFFERSON AVE
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2807
Mailing Address - Country:US
Mailing Address - Phone:901-545-8336
Mailing Address - Fax:901-545-8122
Practice Address - Street 1:2500 PERES AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38108-1660
Practice Address - Country:US
Practice Address - Phone:901-515-5500
Practice Address - Fax:901-458-5591
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2014-08-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN8124367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010278317Medicaid
VA300917OtherANTHEM CROSSOVER PN
VA010278317Medicaid