Healthcare Provider Details

I. General information

NPI: 1609352400
Provider Name (Legal Business Name): TINA M MOY LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TINA M GROCE

II. Dates (important events)

Enumeration Date: 07/14/2018
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 E DUBLIN GRANVILLE RD STE G
WORTHINGTON OH
43085-3183
US

IV. Provider business mailing address

445 E DUBLIN GRANVILLE RD STE G
WORTHINGTON OH
43085-3183
US

V. Phone/Fax

Practice location:
  • Phone: 614-844-3800
  • Fax: 614-844-6258
Mailing address:
  • Phone: 614-844-4380
  • Fax: 614-844-6258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.161413.MEDS-IV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: