Provider Demographics
NPI:1114508488
Name:MOORE, TERRICA (DNP, CPNP-PC)
Entity Type:Individual
Prefix:
First Name:TERRICA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:DNP, CPNP-PC
Other - Prefix:
Other - First Name:EDTERRICA
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6919 LAGRANGE PINES RD
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-2857
Mailing Address - Country:US
Mailing Address - Phone:901-596-6657
Mailing Address - Fax:
Practice Address - Street 1:3674 GOODMAN RD E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-6402
Practice Address - Country:US
Practice Address - Phone:662-890-7747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN202019164363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics