Healthcare Provider Details

I. General information

NPI: 1518682186
Provider Name (Legal Business Name): BA'SHARRA ANEKA MOORE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 03/03/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 2ND ST STE 201
MACON GA
31201-6863
US

IV. Provider business mailing address

890 2ND ST STE 201
MACON GA
31201-6863
US

V. Phone/Fax

Practice location:
  • Phone: 478-745-4322
  • Fax: 478-254-3629
Mailing address:
  • Phone: 478-745-4322
  • Fax: 478-254-3629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN252151
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WN0300X
TaxonomyNephrology Registered Nurse
License NumberRN252151
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: