Provider Demographics
NPI:1821073891
Name:MOORE, STEPHANIE WIGGINS (RN)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:WIGGINS
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 CHASE DR
Mailing Address - Street 2:
Mailing Address - City:EAST DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31027-3395
Mailing Address - Country:US
Mailing Address - Phone:478-275-7650
Mailing Address - Fax:
Practice Address - Street 1:2121A BELLEVUE RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2998
Practice Address - Country:US
Practice Address - Phone:478-272-1190
Practice Address - Fax:478-275-6509
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR125330163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health