Healthcare Provider Details

I. General information

NPI: 1902905060
Provider Name (Legal Business Name): CAROL H MOORE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE INFECTION CONTROL
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

1501 SAN PEDRO DR SE INFECTION CONTROL
ALBUQUERQUE NM
87108-5153
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax: 505-256-2803
Mailing address:
  • Phone: 505-265-1711
  • Fax: 505-256-2803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0600X
TaxonomyInfection Control Registered Nurse
License NumberR45947
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: