Provider Demographics
NPI:1154639805
Name:MOORE, LAVON RENA (NURSE)
Entity Type:Individual
Prefix:MRS
First Name:LAVON
Middle Name:RENA
Last Name:MOORE
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19081 WATERCREST AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-3150
Mailing Address - Country:US
Mailing Address - Phone:216-816-6045
Mailing Address - Fax:126-662-6055
Practice Address - Street 1:19081 WATERCREST AVENUE
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137
Practice Address - Country:US
Practice Address - Phone:216-662-6045
Practice Address - Fax:216-662-6055
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-121466164W00000X, 164X00000X
OHPN121466164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse