Provider Demographics
NPI:1407461791
Name:MOORE, CASEY NICOLE
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:NICOLE
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 1:930 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2616
Mailing Address - Country:US
Mailing Address - Phone:740-788-2299
Mailing Address - Fax:
Practice Address - Street 1:930 WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2616
Practice Address - Country:US
Practice Address - Phone:740-788-2299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-13
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker