Healthcare Provider Details

I. General information

NPI: 1417561168
Provider Name (Legal Business Name): BRANDIE MOORE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

886 HIGHWAY 411 N
ETOWAH TN
37331-1912
US

IV. Provider business mailing address

886 HIGHWAY 411 N
ETOWAH TN
37331-1912
US

V. Phone/Fax

Practice location:
  • Phone: 423-263-3680
  • Fax:
Mailing address:
  • Phone: 423-263-3680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number27952
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number27952
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number27952
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: