Healthcare Provider Details

I. General information

NPI: 1710705686
Provider Name (Legal Business Name): TAYLOR RENEE MOORE NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN ST STE H
DETROIT MI
48201-2119
US

IV. Provider business mailing address

48 CRESCENT DR
PONTIAC MI
48342-2511
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5437
  • Fax: 313-966-6121
Mailing address:
  • Phone: 248-818-0979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number4704325041
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: