Provider Demographics
NPI:1932831856
Name:MOORE, TENISHA RENEE
Entity Type:Individual
Prefix:
First Name:TENISHA
Middle Name:RENEE
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 1:826 MATTMOORE PL
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-4636
Mailing Address - Country:US
Mailing Address - Phone:757-660-5569
Mailing Address - Fax:
Practice Address - Street 1:105 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23693-4334
Practice Address - Country:US
Practice Address - Phone:757-750-0916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019014561225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist