Provider Demographics
NPI:1942667365
Name:MOORE, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
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 1:108 BRIDGEPORT WAY
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34758-4139
Mailing Address - Country:US
Mailing Address - Phone:407-914-6831
Mailing Address - Fax:407-978-6087
Practice Address - Street 1:108 BRIDGEPORT WAY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34758-4139
Practice Address - Country:US
Practice Address - Phone:407-914-6831
Practice Address - Fax:407-978-6087
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-16
Last Update Date:2016-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2872413747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant