Healthcare Provider Details

I. General information

NPI: 1184131914
Provider Name (Legal Business Name): RACHEL ARIEL MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 WAYNE AVE
DAYTON OH
45420-1833
US

IV. Provider business mailing address

2611 WAYNE AVE
DAYTON OH
45420-1833
US

V. Phone/Fax

Practice location:
  • Phone: 937-256-7801
  • Fax:
Mailing address:
  • Phone: 937-256-7801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN.499080
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number152188
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN.499080
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: