Healthcare Provider Details

I. General information

NPI: 1487465324
Provider Name (Legal Business Name): DESTINEY M MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2025
Last Update Date: 01/20/2025
Certification Date: 01/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

972 33RD ST SE
GRAND RAPIDS MI
49508-2435
US

IV. Provider business mailing address

763 5TH ST NW # 2
GRAND RAPIDS MI
49504-5159
US

V. Phone/Fax

Practice location:
  • Phone: 646-775-8413
  • Fax:
Mailing address:
  • Phone: 646-775-8413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: