Provider Demographics
NPI:1558763474
Name:MOORE, NINA (OT)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5710 BAKER RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-5901
Mailing Address - Country:US
Mailing Address - Phone:952-767-4200
Mailing Address - Fax:952-767-4211
Practice Address - Street 1:3800 SILVER BELL RD
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-1653
Practice Address - Country:US
Practice Address - Phone:651-405-0384
Practice Address - Fax:952-767-4211
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104762225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics