Provider Demographics
NPI:1700915469
Name:MOYER, LARRY DWAYNE (LPN)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DWAYNE
Last Name:MOYER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3280 BLACK OAK DR
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45011-9505
Mailing Address - Country:US
Mailing Address - Phone:513-804-7419
Mailing Address - Fax:
Practice Address - Street 1:3280 BLACK OAK DR
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-9505
Practice Address - Country:US
Practice Address - Phone:513-804-7419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN082169374T00000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No374T00000XNursing Service Related ProvidersReligious Nonmedical Nursing Personnel