Provider Demographics
NPI:1477844769
Name:MOORE, THERESA LYNN (LPN)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name: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 1:7398 LIME KILN RD
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14572-9213
Mailing Address - Country:US
Mailing Address - Phone:585-519-2216
Mailing Address - Fax:
Practice Address - Street 1:7398 LIME KILN RD
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:NY
Practice Address - Zip Code:14572-9213
Practice Address - Country:US
Practice Address - Phone:585-519-2216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271025164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY271025Medicaid