Healthcare Provider Details

I. General information

NPI: 1659048460
Provider Name (Legal Business Name): SAMUEL C. MOORE FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2021
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 ELLINGTON DR
LAFAYETTE TN
37083-1697
US

IV. Provider business mailing address

3024 BUSINESS PARK CIR
GOODLETTSVILLE TN
37072-3132
US

V. Phone/Fax

Practice location:
  • Phone: 615-561-1042
  • Fax: 615-561-1043
Mailing address:
  • Phone: 615-239-2018
  • Fax: 615-851-2018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3016346
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number29580
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29580
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number29580
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: