Basic Information
| Provider Information | |||||||||
| NPI: | 1942205083 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | M | ||||||||
| MiddleName: | STEPHANIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 MED TECH PKWY | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237941300 | ||||||||
| FaxNumber: | 4237941820 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 MED TECH PKWY | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237941300 | ||||||||
| FaxNumber: | 4237941820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 04/05/2016 | ||||||||
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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 | 163W00000X | 122889 | TN | N | Nursing Service Providers | Registered Nurse | 363L00000X | 7849 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.