Basic Information
| Provider Information | |||||||||
| NPI: | 1073523882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVORE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 877 JEFFERSON AVE | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015458336 | ||||||||
| FaxNumber: | 9015458122 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 PERES AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381081660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015155500 | ||||||||
| FaxNumber: | 9014585591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 08/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 8124 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 010278317 | 05 | VA | MEDICAID | 300917 | 01 | VA | ANTHEM CROSSOVER PN | OTHER |