Provider Demographics
NPI:1356651541
Name:THOMAS-MOORE, PHYLLIS (RN)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:THOMAS-MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 DENMAN MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:GRAHAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12740-5532
Mailing Address - Country:US
Mailing Address - Phone:845-985-2746
Mailing Address - Fax:
Practice Address - Street 1:6 WIERK AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-2117
Practice Address - Country:US
Practice Address - Phone:845-295-4114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301243-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse