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General NPI Number Information
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NPI Number | 1407940604
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Entity Type | Individual
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Provider Name | PHYLLIS DIANE MOORE I AAS
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Gender | Female
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2710 TROTWOOD AVE
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City | COLUMBIA
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State | TN
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Zip | 38401-4903
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Country | US
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Telephone | 391-388-7182
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Fax |
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Provider Business Mailing Address
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Address Line | 3617 CRAIG BRIDGE RD
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City | WILLIAMSPORT
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State | TN
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Zip | 38487-2160
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Country | US
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Telephone | 931-583-2757
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 246
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License Number State | TN
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