Provider Demographics
NPI:1780226910
Name:MOORE, TAMATHA LYNNE
Entity Type:Individual
Prefix:
First Name:TAMATHA
Middle Name:LYNNE
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 1:11 ARLEY WAY STE 202
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-4883
Mailing Address - Country:US
Mailing Address - Phone:843-757-2273
Mailing Address - Fax:
Practice Address - Street 1:11 ARLEY WAY STE 202
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-4883
Practice Address - Country:US
Practice Address - Phone:843-757-2237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26521363L00000X
SC24167363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner