Healthcare Provider Details

I. General information

NPI: 1003022104
Provider Name (Legal Business Name): DOROTHEA MARIE MOXLEY LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DOROTHEA MARIE INGRAM LPN

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 N OTTERBEIN AVE
WESTERVILLE OH
43081
US

IV. Provider business mailing address

39 N OTTERBEIN AVE
WESTERVILLE OH
43081-1707
US

V. Phone/Fax

Practice location:
  • Phone: 614-674-3816
  • Fax:
Mailing address:
  • Phone: 614-674-3816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number113195
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: