Basic Information
| Provider Information | |||||||||
| NPI: | 1457329302 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STORER | ||||||||
| FirstName: | SALLYANN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | DNP, FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2330 THORNTON TAYLOR PKWY STE B | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373343673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312274984 | ||||||||
| FaxNumber: | 9312274985 | ||||||||
| Practice Location | |||||||||
| Address1: | 2330 THORNTON TAYLOR PKWY STE B | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373343673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312274984 | ||||||||
| FaxNumber: | 9312274985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 363L00000X | APN6630 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3901443 | 05 | TN | MEDICAID |