Provider Demographics
NPI:1457329302
Name:STORER, SALLYANN G (DNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:SALLYANN
Middle Name:G
Last Name:STORER
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 THORNTON TAYLOR PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-3673
Mailing Address - Country:US
Mailing Address - Phone:931-227-4984
Mailing Address - Fax:931-227-4985
Practice Address - Street 1:2330 THORNTON TAYLOR PKWY STE B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-3673
Practice Address - Country:US
Practice Address - Phone:931-227-4984
Practice Address - Fax:931-227-4985
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN6630363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3901443Medicaid
TN1457329302Medicare NSC
TN3901443Medicaid