Provider Demographics
NPI:1689682049
Name:MOORE, SUSAN C (CNS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:MOORE
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6605 W BROAD ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-1714
Mailing Address - Country:US
Mailing Address - Phone:804-287-3000
Mailing Address - Fax:804-282-3314
Practice Address - Street 1:6605 W BROAD ST
Practice Address - Street 2:SUITE A
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1714
Practice Address - Country:US
Practice Address - Phone:804-287-3000
Practice Address - Fax:804-282-3314
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0015000626364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP80357Medicare UPIN
VA000053V63Medicare ID - Type UnspecifiedMEDICARE