Provider Demographics
NPI:1407418403
Name:MOORE, TAMIKA WYNDELLA
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:WYNDELLA
Last Name:MOORE
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 1:132 S BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-3541
Mailing Address - Country:US
Mailing Address - Phone:330-406-6286
Mailing Address - Fax:
Practice Address - Street 1:132 S BEVERLY AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-3541
Practice Address - Country:US
Practice Address - Phone:330-406-6286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN302696164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse