Provider Demographics
NPI:1932781374
Name:MOSLEY, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MOSLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TN
Mailing Address - Zip Code:38372-0655
Mailing Address - Country:US
Mailing Address - Phone:731-925-2300
Mailing Address - Fax:
Practice Address - Street 1:175 ENOCH BLVD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372-2240
Practice Address - Country:US
Practice Address - Phone:319-252-3007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN5725208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program