Provider Demographics
NPI:1275128753
Name:MOORE, DANIELLE LEANDREA (LPN)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:LEANDREA
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 1:1491 HIDDEN HILLS PKWY
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-3120
Mailing Address - Country:US
Mailing Address - Phone:703-861-9358
Mailing Address - Fax:
Practice Address - Street 1:1491 HIDDEN HILLS PKWY
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-3120
Practice Address - Country:US
Practice Address - Phone:703-861-9358
Practice Address - Fax:770-695-0282
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN072524164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse