Provider Demographics
NPI:1114460052
Name:MOORE, MEGAN (STNA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 SPARKS LN
Mailing Address - Street 2:
Mailing Address - City:MINFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45653-8648
Mailing Address - Country:US
Mailing Address - Phone:740-821-1043
Mailing Address - Fax:
Practice Address - Street 1:39 SPARKS LN
Practice Address - Street 2:
Practice Address - City:MINFORD
Practice Address - State:OH
Practice Address - Zip Code:45653-8648
Practice Address - Country:US
Practice Address - Phone:740-821-1043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-26
Last Update Date:2016-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401710971214376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide