Healthcare Provider Details

I. General information

NPI: 1164989448
Provider Name (Legal Business Name): PHYLICIA HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 12/09/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 MADISON AVE
MEMPHIS TN
38103-3409
US

IV. Provider business mailing address

8520 SHADY ELM DR
CORDOVA TN
38018-0404
US

V. Phone/Fax

Practice location:
  • Phone: 901-545-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number24772
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: