Provider Demographics
NPI:1932471513
Name:MOORE, ROSALYN RUSSELL (RN BSN)
Entity Type:Individual
Prefix:MRS
First Name:ROSALYN
Middle Name:RUSSELL
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21951 HARDING ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2556
Mailing Address - Country:US
Mailing Address - Phone:248-968-0564
Mailing Address - Fax:
Practice Address - Street 1:2051 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-1105
Practice Address - Country:US
Practice Address - Phone:313-961-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704130380163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse