Provider Demographics
NPI:1326598582
Name:ANTHONY, CODI MARIE (CNP)
Entity Type:Individual
Prefix:
First Name:CODI
Middle Name:MARIE
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 POPLAR AVE STE 420
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-4806
Mailing Address - Country:US
Mailing Address - Phone:901-843-1045
Mailing Address - Fax:501-843-1206
Practice Address - Street 1:6401 POPLAR AVE STE 420
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4806
Practice Address - Country:US
Practice Address - Phone:901-843-1045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004891363LP0808X
TN29150363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR220185758Medicaid
AR220185758Medicaid