Provider Demographics
NPI:1386214237
Name:MOYER, SIERRA DARLENE
Entity Type:Individual
Prefix:
First Name:SIERRA
Middle Name:DARLENE
Last Name:MOYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SIERRA
Other - Middle Name:DARLENE
Other - Last Name:FANNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:432 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1707
Mailing Address - Country:US
Mailing Address - Phone:815-471-5118
Mailing Address - Fax:
Practice Address - Street 1:423 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HOOPESTON
Practice Address - State:IL
Practice Address - Zip Code:60942-1021
Practice Address - Country:US
Practice Address - Phone:217-283-8247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
IL160009414225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant