Healthcare Provider Details

I. General information

NPI: 1649107673
Provider Name (Legal Business Name): STACEY MOORE AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S BEAUDRY AVE FL 17
LOS ANGELES CA
90017-5105
US

IV. Provider business mailing address

333 S BEAUDRY AVE FL 17
LOS ANGELES CA
90017-5105
US

V. Phone/Fax

Practice location:
  • Phone: 323-293-0985
  • Fax:
Mailing address:
  • Phone: 323-293-0985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAU1837
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: