Healthcare Provider Details

I. General information

NPI: 1083170880
Provider Name (Legal Business Name): KAYLA TIARA MCMORISE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2019
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1995 HIGHWAY 51 S
COVINGTON TN
38019-3635
US

IV. Provider business mailing address

PO BOX 382
HERNANDO MS
38632-0382
US

V. Phone/Fax

Practice location:
  • Phone: 901-476-2621
  • Fax:
Mailing address:
  • Phone: 662-420-1410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number25415
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018072416
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: