Healthcare Provider Details

I. General information

NPI: 1225239411
Provider Name (Legal Business Name): TRENITA LASHAWN MOORE CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRENITA L MAZUR CFNP

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W RAILROAD ST
LONG BEACH MS
39560-4517
US

IV. Provider business mailing address

PO BOX 869 200 W RAILROAD STREET
LONG BEACH MS
39560-0869
US

V. Phone/Fax

Practice location:
  • Phone: 228-864-0622
  • Fax: 228-864-7958
Mailing address:
  • Phone: 228-864-0622
  • Fax: 228-864-7958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR862256
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: