Healthcare Provider Details

I. General information

NPI: 1609418946
Provider Name (Legal Business Name): TIFFANEY M MOORE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12380 PLAZA DR
PARMA OH
44130-1043
US

IV. Provider business mailing address

12380 PLAZA DR
PARMA OH
44130-1043
US

V. Phone/Fax

Practice location:
  • Phone: 216-898-8488
  • Fax: 216-362-0677
Mailing address:
  • Phone: 216-898-8488
  • Fax: 216-362-0677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number024621
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: