Provider Demographics
NPI:1942205083
Name:MOORE, STEPHANIE (DNP, APRN, WHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:DNP, APRN, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4000
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-4000
Mailing Address - Country:US
Mailing Address - Phone:423-926-1171
Mailing Address - Fax:423-979-3591
Practice Address - Street 1:LAMONT STREET AND VETERANS WAY
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-926-1171
Practice Address - Fax:423-979-3591
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN122889163W00000X
TN7849363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP54297Medicare UPIN
TN3348098Medicare PIN