Healthcare Provider Details

I. General information

NPI: 1558641969
Provider Name (Legal Business Name): LISA A MOORE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3444 PLAZA AVE
MEMPHIS TN
38111-4614
US

IV. Provider business mailing address

PO BOX 932958
CLEVELAND OH
44193-0028
US

V. Phone/Fax

Practice location:
  • Phone: 901-730-4204
  • Fax: 901-730-4357
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0000015941
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: