Provider Demographics
NPI:1699385823
Name:MOE, SUZANNE DENISE
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:DENISE
Last Name:MOE
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 1:1858 SE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33035-1932
Mailing Address - Country:US
Mailing Address - Phone:305-807-2217
Mailing Address - Fax:
Practice Address - Street 1:48 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-5942
Practice Address - Country:US
Practice Address - Phone:305-807-2217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13-44-1430868174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist