Provider Demographics
NPI:1548593536
Name:MOORE, RODNEY WAYNE (RN BSN CPAN CAPA)
Entity Type:Individual
Prefix:MR
First Name:RODNEY
Middle Name:WAYNE
Last Name:MOORE
Suffix:
Gender:M
Credentials:RN BSN CPAN CAPA
Other - Prefix:MR
Other - First Name:RODNEY
Other - Middle Name:WAYNE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN BSN CPAN CAPA
Mailing Address - Street 1:1078 FONTAINE PL.
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63137
Mailing Address - Country:US
Mailing Address - Phone:404-918-0461
Mailing Address - Fax:314-868-6605
Practice Address - Street 1:1078 FONTAINE PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63137-1705
Practice Address - Country:US
Practice Address - Phone:404-918-0461
Practice Address - Fax:314-868-6605
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO082489163WP2201X
GARN084407163WP2201X
FLRN9272235163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care