Provider Demographics
NPI:1023402278
Name:MOORE, ANNIE LEE
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:LEE
Last Name:MOORE
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 1:4611 MORTENSEN RD
Mailing Address - Street 2:APT 310
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50014-6227
Mailing Address - Country:US
Mailing Address - Phone:641-895-9929
Mailing Address - Fax:
Practice Address - Street 1:4611 MORTENSEN RD
Practice Address - Street 2:APT 310
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50014-6227
Practice Address - Country:US
Practice Address - Phone:641-895-9929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer