Healthcare Provider Details

I. General information

NPI: 1568200541
Provider Name (Legal Business Name): ANJELICA MOORE MD FAMILY PRACTICE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 CHERRY ST SE STE 100
GRAND RAPIDS MI
49503-4607
US

IV. Provider business mailing address

245 CHERRY ST SE STE 100
GRAND RAPIDS MI
49503-4607
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: