Provider Demographics
NPI:1528395126
Name:MOORE, BESSIE ROSE
Entity Type:Individual
Prefix:
First Name:BESSIE
Middle Name:ROSE
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 1:215 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-3004
Mailing Address - Country:US
Mailing Address - Phone:307-751-1554
Mailing Address - Fax:
Practice Address - Street 1:215 W 6TH ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3004
Practice Address - Country:US
Practice Address - Phone:307-751-1554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator