Healthcare Provider Details

I. General information

NPI: 1255209862
Provider Name (Legal Business Name): TIERRA LA'SHAY MOORE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2025
Last Update Date: 10/27/2025
Certification Date: 10/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W MARTIN LUTHER KING JR DR
WASHINGTON NC
27889-4906
US

IV. Provider business mailing address

120 W MARTIN LUTHER KING JR DR
WASHINGTON NC
27889-4906
US

V. Phone/Fax

Practice location:
  • Phone: 252-940-0602
  • Fax:
Mailing address:
  • Phone: 252-940-0602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5023360
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: