Provider Demographics
NPI:1134756851
Name:MOORE, ALEXANDRA ROSE
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:ROSE
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 1:915 36TH ST E
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1522
Mailing Address - Country:US
Mailing Address - Phone:229-326-9517
Mailing Address - Fax:
Practice Address - Street 1:915 36TH ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1522
Practice Address - Country:US
Practice Address - Phone:229-326-9517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor