Provider Demographics
NPI:1255577912
Name:LEWIS MOORE, NAKITIA MELISSA (LPN)
Entity type:Individual
Prefix:MISS
First Name:NAKITIA
Middle Name:MELISSA
Last Name:LEWIS MOORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3986 E 123RD ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-4502
Mailing Address - Country:US
Mailing Address - Phone:216-220-7217
Mailing Address - Fax:
Practice Address - Street 1:3986 E 123RD ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-4502
Practice Address - Country:US
Practice Address - Phone:216-220-7217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-31
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH132645164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2893614Medicaid