Provider Demographics
NPI:1952480816
Name:MOORE, DONNA D (CRNA)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 FORT HENRY DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-2240
Mailing Address - Country:US
Mailing Address - Phone:423-239-5833
Mailing Address - Fax:423-239-9789
Practice Address - Street 1:4105 FORT HENRY DR
Practice Address - Street 2:SUITE 207
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-2240
Practice Address - Country:US
Practice Address - Phone:423-239-5833
Practice Address - Fax:423-239-9789
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21382174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist