Provider Demographics
NPI:1831761865
Name:MOORE, MARY JANE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JANE
Other - Last Name:COMBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 S SEWARD MERIDIAN PKWY # ABC
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8312
Mailing Address - Country:US
Mailing Address - Phone:907-631-3520
Mailing Address - Fax:
Practice Address - Street 1:1401 S SEWARD MERIDIAN PKWY # ABC
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8312
Practice Address - Country:US
Practice Address - Phone:907-631-3520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist