Provider Demographics
NPI:1568990489
Name:MOORE, HEATHER COLLEEN (RNFA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:COLLEEN
Last Name:MOORE
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:COLLEEN
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RNFA
Mailing Address - Street 1:109 MONTE VIS
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-2003
Mailing Address - Country:US
Mailing Address - Phone:559-301-0248
Mailing Address - Fax:
Practice Address - Street 1:16250 SAND CANYON AVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3714
Practice Address - Country:US
Practice Address - Phone:949-727-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA684156208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery