Provider Demographics
NPI:1225392574
Name:MOORE, TRACI ANN (LPN)
Entity Type:Individual
Prefix:MISS
First Name:TRACI
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5278 SOUTHWESTERN BLVD
Mailing Address - Street 2:UNIT 904
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-8000
Mailing Address - Country:US
Mailing Address - Phone:716-649-8375
Mailing Address - Fax:
Practice Address - Street 1:5278 SOUTHWESTERN BLVD
Practice Address - Street 2:UNIT 904
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-8000
Practice Address - Country:US
Practice Address - Phone:716-649-8375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10244744164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse