Provider Demographics
NPI:1497093546
Name:MOORE, VANESSA JOSEPHINE
Entity Type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:JOSEPHINE
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 1:2612 DOGWOOD AVE
Mailing Address - Street 2:PT D19
Mailing Address - City:THUNDERBOLT
Mailing Address - State:GA
Mailing Address - Zip Code:31404-3239
Mailing Address - Country:US
Mailing Address - Phone:912-220-6689
Mailing Address - Fax:
Practice Address - Street 1:2612 DOGWOOD AVE
Practice Address - Street 2:PT D19
Practice Address - City:THUNDERBOLT
Practice Address - State:GA
Practice Address - Zip Code:31404-3239
Practice Address - Country:US
Practice Address - Phone:912-220-6689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist