Provider Demographics
NPI:1225014962
Name:MOORE, MELISSA ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:MISSY
Other - Middle Name:ANN
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4013 PARKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT JOY
Mailing Address - State:PA
Mailing Address - Zip Code:17552-9253
Mailing Address - Country:US
Mailing Address - Phone:717-560-4200
Mailing Address - Fax:717-560-6380
Practice Address - Street 1:231 GRANITE RUN DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-6823
Practice Address - Country:US
Practice Address - Phone:717-560-4200
Practice Address - Fax:717-560-6380
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2008-12-03
Deactivation Date:2006-05-25
Deactivation Code:
Reactivation Date:2008-12-03
Provider Licenses
StateLicense IDTaxonomies
PAPT007638L2251X0800X
PAPT-007638-L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1659162OtherHIGH MARK BLUE SHIELD
PA50048578OtherCAPITOL BLUE CROSS
PA084513D1XMedicare UPIN
PA1659162OtherHIGH MARK BLUE SHIELD
PAQ26377Medicare UPIN