Provider Demographics
NPI:1629543939
Name:MOORER, DESARAE S
Entity Type:Individual
Prefix:
First Name:DESARAE
Middle Name:S
Last Name:MOORER
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 1:6309 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-2302
Mailing Address - Country:US
Mailing Address - Phone:313-575-4211
Mailing Address - Fax:
Practice Address - Street 1:6309 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2302
Practice Address - Country:US
Practice Address - Phone:313-575-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX338628164X00000X
MI4704392950163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse