Healthcare Provider Details

I. General information

NPI: 1871574459
Provider Name (Legal Business Name): MS. PATRICIA D MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WETUPKA WAY
HERNANDO MS
38632-4420
US

IV. Provider business mailing address

11301 WETUPKA WAY
HERNANDO MS
38632-4420
US

V. Phone/Fax

Practice location:
  • Phone: 662-429-5835
  • Fax: 662-449-0443
Mailing address:
  • Phone: 662-429-5835
  • Fax: 662-449-0443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: