Provider Demographics
NPI:1912030040
Name:MOORE, CATHERINE (RN)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
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 1:24 WESTBROOK LN
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1016
Mailing Address - Country:US
Mailing Address - Phone:516-623-3362
Mailing Address - Fax:
Practice Address - Street 1:333 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-1231
Practice Address - Country:US
Practice Address - Phone:516-623-3362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236735-1163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY236735-1OtherLICENSE