Provider Demographics
NPI:1821640400
Name:MOSS, LARRY DWAYNE (LVN)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DWAYNE
Last Name:MOSS
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 W TEXAS ST APT 136
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-4472
Mailing Address - Country:US
Mailing Address - Phone:808-351-2054
Mailing Address - Fax:
Practice Address - Street 1:150 MUIR RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4668
Practice Address - Country:US
Practice Address - Phone:808-351-2054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX347953164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse