Basic Information
| Provider Information | |||||||||
| NPI: | 1467567255 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | SHERRY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE PRIME CARE DRIVE | ||||||||
| Address2: | PRIME CARE MEDICAL CENTER | ||||||||
| City: | SELMER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316457932 | ||||||||
| FaxNumber: | 7316455195 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE PRIME CARE DRIVE | ||||||||
| Address2: | |||||||||
| City: | SELMER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316457932 | ||||||||
| FaxNumber: | 7316455195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363LF0000X | APN05064 | TN | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | RN027447 | TN | X | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 4038058 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 23178 | 01 | TN | TLC | OTHER |