Healthcare Provider Details

I. General information

NPI: 1487027744
Provider Name (Legal Business Name): WILLIE MOSES REGISTERED NURSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BILL MOSES REGISTERED NURSE

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 E FLOWER ST APT 267
CHULA VISTA CA
91910-7611
US

IV. Provider business mailing address

55 E FLOWER ST APT 267
CHULA VISTA CA
91910-7611
US

V. Phone/Fax

Practice location:
  • Phone: 619-913-0168
  • Fax:
Mailing address:
  • Phone: 619-913-0168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number517746
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: