MEDICARE: ANDREA JENAE MOSS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	9066300-4104	UT

General Provider Information

NPI Number	:	1720489107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA JENAE MOSS

Provider Business Mailing Address
First Line	:	7748 S ROPE KEY DR APT H208
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-7567
Country	:	US
Telephone Number	:	313-671-4985
Fax Number	:

Provider Business Practice Location Address
First Line	:	433 E 2700 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-3325
Country	:	US
Telephone Number	:	313-671-4985
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2014
Last Update Date	:	02/08/2017

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Directions to “ ANDREA JENAE MOSS ” Practice Location

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