Provider Demographics
NPI:1700603677
Name:MOORE, YEZELL P
Entity type:Individual
Prefix:
First Name:YEZELL
Middle Name:P
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 1:869 VAN SICLEN AVE APT 1J
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-7800
Mailing Address - Country:US
Mailing Address - Phone:929-277-2144
Mailing Address - Fax:
Practice Address - Street 1:869 VAN SICLEN AVE APT 1J
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-7800
Practice Address - Country:US
Practice Address - Phone:929-277-2144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY585189051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist