Provider Demographics
NPI:1497533947
Name:MOORE, JALA (RN)
Entity Type:Individual
Prefix:
First Name:JALA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 ALICE WAGNER WAY APT 11
Mailing Address - Street 2:
Mailing Address - City:NISKAYUNA
Mailing Address - State:NY
Mailing Address - Zip Code:12309-3563
Mailing Address - Country:US
Mailing Address - Phone:716-290-9413
Mailing Address - Fax:
Practice Address - Street 1:3 ALICE WAGNER WAY APT 11
Practice Address - Street 2:
Practice Address - City:NISKAYUNA
Practice Address - State:NY
Practice Address - Zip Code:12309-3563
Practice Address - Country:US
Practice Address - Phone:716-290-9413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY853274-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse