Provider Demographics
NPI:1598250201
Name:MOORE, LAWANDA ROCHELLE
Entity Type:Individual
Prefix:
First Name:LAWANDA
Middle Name:ROCHELLE
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 1:5421 N 103RD ST STE 401
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-1010
Mailing Address - Country:US
Mailing Address - Phone:402-393-2525
Mailing Address - Fax:402-393-2441
Practice Address - Street 1:5421 N 103RD ST STE 401
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-1010
Practice Address - Country:US
Practice Address - Phone:402-393-2525
Practice Address - Fax:402-393-2441
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEHHA202002374U00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1598250201Medicaid