Provider Demographics
NPI:1710570494
Name:MOORE, MYESHA D (LPN)
Entity Type:Individual
Prefix:
First Name:MYESHA
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:HULL
Mailing Address - State:GA
Mailing Address - Zip Code:30646-3842
Mailing Address - Country:US
Mailing Address - Phone:678-598-5945
Mailing Address - Fax:
Practice Address - Street 1:250 BRAY ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-2203
Practice Address - Country:US
Practice Address - Phone:706-389-6789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-14
Last Update Date:2021-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5241012164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse