Provider Demographics
NPI:1861041865
Name:MOORE, EBONIE MONIQUE
Entity Type:Individual
Prefix:
First Name:EBONIE
Middle Name:MONIQUE
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 1:3538 LANTERN VIEW LN
Mailing Address - Street 2:
Mailing Address - City:SCOTTDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30079-6806
Mailing Address - Country:US
Mailing Address - Phone:470-269-4271
Mailing Address - Fax:
Practice Address - Street 1:3538 LANTERN VIEW LN
Practice Address - Street 2:
Practice Address - City:SCOTTDALE
Practice Address - State:GA
Practice Address - Zip Code:30079-6806
Practice Address - Country:US
Practice Address - Phone:470-269-4271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor