Healthcare Provider Details

I. General information

NPI: 1447727987
Provider Name (Legal Business Name): ALEXANDER GRAY MOORE DNP, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2018
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PARK BLVD FL 5
BRISTOL TN
37620-7430
US

IV. Provider business mailing address

105 W STONE DR STE 6A
KINGSPORT TN
37660-3256
US

V. Phone/Fax

Practice location:
  • Phone: 423-844-6000
  • Fax: 423-844-6027
Mailing address:
  • Phone: 423-408-7220
  • Fax: 423-408-7405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number24675
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number207815
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: