Basic Information
| Provider Information | |||||||||
| NPI: | 1912589540 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANCOCK | ||||||||
| FirstName: | ADDIE | ||||||||
| MiddleName: | MOORE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9126 HIGHWAY 11 W | ||||||||
| Address2: | |||||||||
| City: | MOORESBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378112314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283352305 | ||||||||
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| Practice Location | |||||||||
| Address1: | MEDICAL CENTER BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2021 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.