Provider Demographics
NPI:1447786223
Name:MOFFETT, GENEATH
Entity Type:Individual
Prefix:
First Name:GENEATH
Middle Name:
Last Name:MOFFETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 COLIBRI WAY
Mailing Address - Street 2:APT 106
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-8914
Mailing Address - Country:US
Mailing Address - Phone:321-514-6006
Mailing Address - Fax:
Practice Address - Street 1:110 COLIBRI WAY
Practice Address - Street 2:APT 106
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-8914
Practice Address - Country:US
Practice Address - Phone:321-514-6006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator