Provider Demographics
NPI:1801375449
Name:MOORE-CLEMMONS, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:MOORE-CLEMMONS
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 1:8122 WADE PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-2966
Mailing Address - Country:US
Mailing Address - Phone:216-990-8380
Mailing Address - Fax:
Practice Address - Street 1:8122 WADE PARK AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-2966
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH349074163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse