MEDICARE: TIANNA R. MOORE

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	172A00000X	Driver	2167500	DE

General Provider Information

NPI Number	:	1902668437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIANNA R. MOORE

Provider Business Mailing Address
First Line	:	411 QUINCY AVE
Second Line	:
City	:	MIDDLETOWN
State	:	DE
Zip	:	19709-8368
Country	:	US
Telephone Number	:	215-397-5955
Fax Number	:

Provider Business Practice Location Address
First Line	:	2839 W GIRARD AVE FL 1
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-1214
Country	:	US
Telephone Number	:	215-397-5955
Fax Number	:

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

Provider Enumeration Date	:	01/29/2024
Last Update Date	:	01/29/2024

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Directions to “ TIANNA R. MOORE ” Practice Location

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