Provider Demographics
NPI:1275176893
Name:MOSES, ETHEL LEE
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:LEE
Last Name:MOSES
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 1:1511 W GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-4843
Mailing Address - Country:US
Mailing Address - Phone:229-449-4123
Mailing Address - Fax:
Practice Address - Street 1:1511 W GORDON AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-4843
Practice Address - Country:US
Practice Address - Phone:229-449-4123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-26
Last Update Date:2019-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054598352171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor