Provider Demographics
NPI:1912892316
Name:MOORE, MEREDITH (SA)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 ROGERS DR
Mailing Address - Street 2:
Mailing Address - City:NETTLETON
Mailing Address - State:MS
Mailing Address - Zip Code:38858-6014
Mailing Address - Country:US
Mailing Address - Phone:662-614-4803
Mailing Address - Fax:
Practice Address - Street 1:114 ROGERS DR
Practice Address - Street 2:
Practice Address - City:NETTLETON
Practice Address - State:MS
Practice Address - Zip Code:38858-6014
Practice Address - Country:US
Practice Address - Phone:662-614-4803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0136001058246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant