Healthcare Provider Details

I. General information

NPI: 1477756435
Provider Name (Legal Business Name): LESLIE DANICE WOODMAN-MOORE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9680 CITRUS AVE BUILDING #33
FONTANA CA
92335-5571
US

IV. Provider business mailing address

9680 CITRUS AVE BUILDING #33
FONTANA CA
92335-5571
US

V. Phone/Fax

Practice location:
  • Phone: 909-357-5000
  • Fax:
Mailing address:
  • Phone: 909-357-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number370255
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: