Provider Demographics
NPI:1841639762
Name:MOORE, NASTASSJA R (NP)
Entity type:Individual
Prefix:
First Name:NASTASSJA
Middle Name:R
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2341 MCCALLIE AVE STE 403
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-3227
Mailing Address - Country:US
Mailing Address - Phone:423-602-9674
Mailing Address - Fax:423-602-9690
Practice Address - Street 1:2341 MCCALLIE AVE STE 403
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404
Practice Address - Country:US
Practice Address - Phone:423-602-9674
Practice Address - Fax:423-602-9690
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN161491163W00000X
TN17742363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ000920Medicaid
GA003136096AMedicaid
TNQ000920Medicaid