Provider Demographics
NPI:1013042514
Name:MOORE, WANDA D (DME)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:DME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 N LIMESTONE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2635
Mailing Address - Country:US
Mailing Address - Phone:937-399-6477
Mailing Address - Fax:
Practice Address - Street 1:2213 N LIMESTONE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2635
Practice Address - Country:US
Practice Address - Phone:937-399-6477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4596580002Medicare NSC