Provider Demographics
NPI:1225239411
Name:MOORE, TRENITA LASHAWN (CFNP)
Entity Type:Individual
Prefix:MS
First Name:TRENITA
Middle Name:LASHAWN
Last Name:MOORE
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:TRENITA
Other - Middle Name:L
Other - Last Name:MAZUR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CFNP
Mailing Address - Street 1:PO BOX 869
Mailing Address - Street 2:200 W RAILROAD STREET
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-0869
Mailing Address - Country:US
Mailing Address - Phone:228-864-0622
Mailing Address - Fax:228-864-7958
Practice Address - Street 1:200 W RAILROAD ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-4517
Practice Address - Country:US
Practice Address - Phone:228-864-0622
Practice Address - Fax:228-864-7958
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR862256363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0620608060Medicaid