Provider Demographics
NPI:1619279858
Name:MOORE, DONNA EALISE'
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:EALISE'
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 1:7485 FALCON ROCK DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-1472
Mailing Address - Country:US
Mailing Address - Phone:702-412-5537
Mailing Address - Fax:702-202-3043
Practice Address - Street 1:7485 FALCON ROCK DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-1472
Practice Address - Country:US
Practice Address - Phone:702-412-5537
Practice Address - Fax:702-202-3043
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-20
Last Update Date:2010-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner