Provider Demographics
NPI:1407940604
Name:MOORE, PHYLLIS DIANE I (AAS)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:DIANE
Last Name:MOORE
Suffix:I
Gender:F
Credentials:AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3617 CRAIG BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:38487-2160
Mailing Address - Country:US
Mailing Address - Phone:931-583-2757
Mailing Address - Fax:
Practice Address - Street 1:2710 TROTWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4903
Practice Address - Country:US
Practice Address - Phone:391-388-7182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN246225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant