Provider Demographics
NPI:1689261224
Name:PRINCESS-MOORE, DELY MICHELE
Entity Type:Individual
Prefix:
First Name:DELY
Middle Name:MICHELE
Last Name:PRINCESS-MOORE
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 1:2049 RANDY SCOTT DR APT B
Mailing Address - Street 2:
Mailing Address - City:WEST CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-2622
Mailing Address - Country:US
Mailing Address - Phone:269-586-4115
Mailing Address - Fax:
Practice Address - Street 1:2049 RANDY SCOTT DR APT B
Practice Address - Street 2:
Practice Address - City:WEST CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:45449-2622
Practice Address - Country:US
Practice Address - Phone:269-586-4115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program