Provider Demographics
NPI:1184018624
Name:MOORE, CHANDELL (RN,PHN,BSN)
Entity Type:Individual
Prefix:MRS
First Name:CHANDELL
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN,PHN,BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 HUME GLENN DR
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-8397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11484 B AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2603
Practice Address - Country:US
Practice Address - Phone:530-886-3624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025744163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management