Provider Demographics
NPI:1467839928
Name:MOORE, TIFFANY
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:
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 1:8400 WEST CHALESTON BLVD APT 208
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117
Mailing Address - Country:US
Mailing Address - Phone:702-624-7796
Mailing Address - Fax:
Practice Address - Street 1:8400 W CHARLESTON BLVD APT 208
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-9034
Practice Address - Country:US
Practice Address - Phone:702-624-7796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2000418531347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle