Healthcare Provider Details

I. General information

NPI: 1922822972
Provider Name (Legal Business Name): OLIVIA ELIZABETH MOORE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 11/14/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 STATE ST STE 300
ROCHESTER NY
14614-1353
US

IV. Provider business mailing address

280 VILLAGE II DRIVE D
HILTON NY
14468
US

V. Phone/Fax

Practice location:
  • Phone: 585-454-3550
  • Fax:
Mailing address:
  • Phone: 585-694-5564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number348694-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: