Provider Demographics
NPI:1407287618
Name:MOORE, AMBER DAWN (STNA)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:DAWN
Last Name:MOORE
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:DAWN
Other - Last Name:SOWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:208 E JEFFERSON ST LOT 2
Mailing Address - Street 2:
Mailing Address - City:NEW LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43764-1076
Mailing Address - Country:US
Mailing Address - Phone:740-621-1605
Mailing Address - Fax:
Practice Address - Street 1:208 E JEFFERSON ST LOT 2
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764-1076
Practice Address - Country:US
Practice Address - Phone:740-621-1605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH379740710401376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide