Healthcare Provider Details

I. General information

NPI: 1184962664
Provider Name (Legal Business Name): ABBY JO MOORE CD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 N 1ST ST
GRAYVILLE IL
62844-1016
US

IV. Provider business mailing address

840 N 1ST ST
GRAYVILLE IL
62844-1016
US

V. Phone/Fax

Practice location:
  • Phone: 618-518-9099
  • Fax:
Mailing address:
  • Phone: 618-518-9099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: