Provider Demographics
NPI:1225667314
Name:ABERE, MOYOSORE MARY (NP)
Entity Type:Individual
Prefix:MRS
First Name:MOYOSORE
Middle Name:MARY
Last Name:ABERE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 S SHERBOURNE DR PH 5
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-2369
Mailing Address - Country:US
Mailing Address - Phone:404-543-3609
Mailing Address - Fax:
Practice Address - Street 1:14445 OLIVE VIEW DR
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1437
Practice Address - Country:US
Practice Address - Phone:747-210-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017820363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN281354OtherGEORGIA APRN NUMBER