Provider Demographics
NPI:1083761514
Name:MOORE, ROLLANDA FAYETTE (PT, DPT, RN, BSN, MS)
Entity Type:Individual
Prefix:
First Name:ROLLANDA
Middle Name:FAYETTE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT, DPT, RN, BSN, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6338 SNIDER RD UNIT 104
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-5105
Mailing Address - Country:US
Mailing Address - Phone:513-204-9718
Mailing Address - Fax:513-672-2688
Practice Address - Street 1:6338 SNIDER RD UNIT 104
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-5105
Practice Address - Country:US
Practice Address - Phone:321-208-3891
Practice Address - Fax:309-692-2885
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH507594163W00000X
FL9606549163W00000X
KY1179225163W00000X
FL20357225100000X
OH016715225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No163W00000XNursing Service ProvidersRegistered Nurse