Provider Demographics
NPI:1851441604
Name:MOORE, ANGELA B
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:B
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 1:2543 LAUREL VIEW CT
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6805
Mailing Address - Country:US
Mailing Address - Phone:678-468-8533
Mailing Address - Fax:678-344-1560
Practice Address - Street 1:2543 LAUREL VIEW CT
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6805
Practice Address - Country:US
Practice Address - Phone:678-468-8533
Practice Address - Fax:678-344-1560
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00904747BMedicaid