Provider Demographics
NPI:1225276645
Name:MOORE, DEANA GAY
Entity Type:Individual
Prefix:
First Name:DEANA
Middle Name:GAY
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 OAKBROOK CT APT 1
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2242
Mailing Address - Country:US
Mailing Address - Phone:309-530-6075
Mailing Address - Fax:
Practice Address - Street 1:108 W MARKET ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3918
Practice Address - Country:US
Practice Address - Phone:309-827-5351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041269898163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health