Healthcare Provider Details

I. General information

NPI: 1659524148
Provider Name (Legal Business Name): SHOT NURSE-MEMPHIS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 07/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4637 POPLAR AVE
MEMPHIS TN
38117-4419
US

IV. Provider business mailing address

4637 POPLAR AVE
MEMPHIS TN
38117-4419
US

V. Phone/Fax

Practice location:
  • Phone: 901-685-9999
  • Fax: 901-767-8388
Mailing address:
  • Phone: 901-685-9999
  • Fax: 901-767-8388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH YVONNE OVERALL
Title or Position: VICE-PRESIDENT
Credential: RN
Phone: 901-685-9999