Provider Demographics
NPI:1376221689
Name:MOSS, JOANN CARMESHA
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:CARMESHA
Last Name:MOSS
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 1:8203 ROBSON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-2457
Mailing Address - Country:US
Mailing Address - Phone:313-690-9324
Mailing Address - Fax:
Practice Address - Street 1:9313 MONTROSE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-2126
Practice Address - Country:US
Practice Address - Phone:313-293-0423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization