Provider Demographics
NPI:1720577109
Name:MOORE, DEAUNWAY
Entity Type:Individual
Prefix:
First Name:DEAUNWAY
Middle Name:
Last Name: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 1:13314 DICKENS LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35756-3529
Mailing Address - Country:US
Mailing Address - Phone:256-655-5829
Mailing Address - Fax:
Practice Address - Street 1:13314 DICKENS LN
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35756-3529
Practice Address - Country:US
Practice Address - Phone:256-655-5829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management