Provider Demographics
NPI:1053040303
Name:MOORE, CARLA
Entity Type:Individual
Prefix:
First Name:CARLA
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 1:2724 PEBBLE WAY
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-7978
Mailing Address - Country:US
Mailing Address - Phone:208-571-8710
Mailing Address - Fax:
Practice Address - Street 1:2724 PEBBLE WAY
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-7978
Practice Address - Country:US
Practice Address - Phone:208-571-8710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDBB234643E374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide