Provider Demographics
NPI:1235709171
Name:MOORE, ANDREA (PTA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 SQUIRE FOX RD
Mailing Address - Street 2:
Mailing Address - City:DANDRIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37725-6105
Mailing Address - Country:US
Mailing Address - Phone:574-220-5570
Mailing Address - Fax:
Practice Address - Street 1:1435 SQUIRE FOX RD
Practice Address - Street 2:
Practice Address - City:DANDRIDGE
Practice Address - State:TN
Practice Address - Zip Code:37725-6105
Practice Address - Country:US
Practice Address - Phone:574-220-5570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7623225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant