=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255908026
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FULL MOON PSYCHIATRIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2021
-----------------------------------------------------
Last Update Date | 06/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5810 SHELBY OAKS DR STE B
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38134-7315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-371-7125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2033 FORT CAMPBELL BLVD STE A PMB 1071
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | ALECIA WHITE
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 931-371-7125
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------