Provider Demographics
NPI:1700398625
Name:MOORE, LESHANTE A (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LESHANTE
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:LESHANTE
Other - Middle Name:A
Other - Last Name:FAIRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:PO BOX 69030
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9030
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:612 DENBIGH BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-4416
Practice Address - Country:US
Practice Address - Phone:757-874-0032
Practice Address - Fax:757-874-0127
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherGROUP MEDICARE PTAN