MEDICARE: DONNA D MOORE CRNA

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	174400000X	Specialist	21382	TN

General Provider Information

NPI Number	:	1952480816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA D MOORE CRNA

Provider Business Mailing Address
First Line	:	4105 FORT HENRY DR
Second Line	:	SUITE 207
City	:	KINGSPORT
State	:	TN
Zip	:	37663-2240
Country	:	US
Telephone Number	:	423-239-5833
Fax Number	:	423-239-9789

Provider Business Practice Location Address
First Line	:	4105 FORT HENRY DR
Second Line	:	SUITE 207
City	:	KINGSPORT
State	:	TN
Zip	:	37663-2240
Country	:	US
Telephone Number	:	423-239-5833
Fax Number	:	423-239-9789

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

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	07/08/2007

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Directions to “ DONNA D MOORE CRNA” Practice Location

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