Provider Demographics
NPI:1669820130
Name:MOORE, MIKAYLA ASHLYN (MAT, ATC)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:ASHLYN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14701 COPPER RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75706-3364
Mailing Address - Country:US
Mailing Address - Phone:903-714-3515
Mailing Address - Fax:
Practice Address - Street 1:14701 COPPER RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75706-3364
Practice Address - Country:US
Practice Address - Phone:903-714-3515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20000236682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer