Provider Demographics
NPI:1033721659
Name:MOORE, BREANNA
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
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 1:15946 MCLANE PIKE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:WV
Mailing Address - Zip Code:25124
Mailing Address - Country:US
Mailing Address - Phone:304-932-7562
Mailing Address - Fax:
Practice Address - Street 1:15946 MCLANE PIKE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:WV
Practice Address - Zip Code:25124
Practice Address - Country:US
Practice Address - Phone:304-932-7562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant