Provider Demographics
NPI:1972843621
Name:MOORE, BEVERLY A
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:A
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 1:830 DAYSPRING CT
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:OH
Mailing Address - Zip Code:45067-9629
Mailing Address - Country:US
Mailing Address - Phone:706-495-2735
Mailing Address - Fax:
Practice Address - Street 1:830 DAYSPRING CT
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:OH
Practice Address - Zip Code:45067-9629
Practice Address - Country:US
Practice Address - Phone:706-495-2735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 137552164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse