Healthcare Provider Details

I. General information

NPI: 1134959349
Provider Name (Legal Business Name): AMIE NICOLE MOORE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1139 MAIN AVE
WARWICK RI
02886-1940
US

IV. Provider business mailing address

22 TRENT AVE
WARWICK RI
02889-8275
US

V. Phone/Fax

Practice location:
  • Phone: 401-739-6600
  • Fax:
Mailing address:
  • Phone: 401-523-3265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA01261
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: