Provider Demographics
NPI:1710761127
Name:FARRIS PEDIATRIC PRIMARY CARE CONCEPT, LLC
Entity Type:Organization
Organization Name:FARRIS PEDIATRIC PRIMARY CARE CONCEPT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:FARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:PPCNP-BC
Authorized Official - Phone:901-409-0506
Mailing Address - Street 1:2059 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38127-3933
Mailing Address - Country:US
Mailing Address - Phone:901-409-0506
Mailing Address - Fax:
Practice Address - Street 1:4250 FARONIA RD STE 2A
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6250
Practice Address - Country:US
Practice Address - Phone:901-236-7707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty