Provider Demographics
NPI:1205837358
Name:MOORE, CHERI LYN (CRNA)
Entity Type:Individual
Prefix:MS
First Name:CHERI
Middle Name:LYN
Last Name:MOORE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 VALVERDE CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5935
Mailing Address - Country:US
Mailing Address - Phone:817-481-7544
Mailing Address - Fax:
Practice Address - Street 1:3500 INTERSTATE 30 AT MOTLEY DR.
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150
Practice Address - Country:US
Practice Address - Phone:972-698-2051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2008-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX235104367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX002291501Medicaid
TX090153005Medicaid
TX090153005Medicaid
TX002291501Medicaid