Provider Demographics
NPI:1619913506
Name:MOORE, PENELOPE S (PT)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:S
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:H
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 211
Mailing Address - Street 2:
Mailing Address - City:METTER
Mailing Address - State:GA
Mailing Address - Zip Code:30439-0211
Mailing Address - Country:US
Mailing Address - Phone:912-685-4331
Mailing Address - Fax:912-685-4476
Practice Address - Street 1:8 N WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:METTER
Practice Address - State:GA
Practice Address - Zip Code:30439-4547
Practice Address - Country:US
Practice Address - Phone:912-685-4331
Practice Address - Fax:912-685-4476
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT001084225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000848768CMedicaid
GA65BBBLWMedicare ID - Type Unspecified
GA000848768CMedicaid