Provider Demographics
NPI:1568778355
Name:MOORE, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
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 1:6995 DORSEY EVERGREEN RD
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MS
Mailing Address - Zip Code:38843-7743
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6995 DORSEY EVERGREEN RD
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MS
Practice Address - Zip Code:38843-7743
Practice Address - Country:US
Practice Address - Phone:662-397-0202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA2287174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist