Provider Demographics
NPI:1295068211
Name:MOORE, AMBER NICOLE
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:NICOLE
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 1:4634 W NORTHGATE DR # 240
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-2404
Mailing Address - Country:US
Mailing Address - Phone:318-512-2696
Mailing Address - Fax:
Practice Address - Street 1:4634 W NORTHGATE DR # 240
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-2404
Practice Address - Country:US
Practice Address - Phone:318-512-2696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program