Provider Demographics
NPI:1780845677
Name:MOORE, MICHELLE LEE (LPN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
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 1:2772 CENTER RD
Mailing Address - Street 2:APT 4
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-5112
Mailing Address - Country:US
Mailing Address - Phone:330-318-7754
Mailing Address - Fax:
Practice Address - Street 1:2772 CENTER RD
Practice Address - Street 2:APT 4
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-5112
Practice Address - Country:US
Practice Address - Phone:330-318-7754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-109532164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse