Provider Demographics
NPI:1063838803
Name:MOORE, SANDY (RN)
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-2673
Mailing Address - Country:US
Mailing Address - Phone:843-719-4608
Mailing Address - Fax:843-719-4656
Practice Address - Street 1:109 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-2673
Practice Address - Country:US
Practice Address - Phone:843-719-4608
Practice Address - Fax:843-719-4656
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC81304163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health