Provider Demographics
NPI:1639431323
Name:MOORE-GUILLAUME, KAREN (MSED)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:MOORE-GUILLAUME
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MILITARY DR
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-1920
Mailing Address - Country:US
Mailing Address - Phone:315-682-1750
Mailing Address - Fax:
Practice Address - Street 1:171 INTREPID LN
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-2548
Practice Address - Country:US
Practice Address - Phone:315-437-4689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist