Provider Demographics
NPI:1659649002
Name:MOORE, JACQUELINE HISTORIAN (LPN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:HISTORIAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6256 HILLANDALE DR APT 803
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-2432
Mailing Address - Country:US
Mailing Address - Phone:678-913-7277
Mailing Address - Fax:
Practice Address - Street 1:6256 HILLANDALE DR APT 803
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-2432
Practice Address - Country:US
Practice Address - Phone:678-913-7277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN085771164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse