Provider Demographics
NPI:1669772737
Name:MOORE, MILLIE
Entity type:Individual
Prefix:
First Name:MILLIE
Middle Name:
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 1:342 ATWATER RD
Mailing Address - Street 2:
Mailing Address - City:CHATTAHOOCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:32324-3121
Mailing Address - Country:US
Mailing Address - Phone:850-442-6625
Mailing Address - Fax:
Practice Address - Street 1:283 COCHRAN RD
Practice Address - Street 2:
Practice Address - City:CHATTAHOOCHEE
Practice Address - State:FL
Practice Address - Zip Code:32324-3607
Practice Address - Country:US
Practice Address - Phone:850-442-6625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-23
Last Update Date:2010-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide