Provider Demographics
NPI:1922282573
Name:PHIFER, CHARONDA LYNNICE (FNP)
Entity type:Individual
Prefix:
First Name:CHARONDA
Middle Name:LYNNICE
Last Name:PHIFER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4613 JACOB LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6408
Mailing Address - Country:US
Mailing Address - Phone:310-648-4343
Mailing Address - Fax:
Practice Address - Street 1:2430 POPLAR AVE STE 100
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-3246
Practice Address - Country:US
Practice Address - Phone:866-711-1717
Practice Address - Fax:901-339-6509
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20733363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABI467ZMedicare UPIN