Healthcare Provider Details

I. General information

NPI: 1982608915
Provider Name (Legal Business Name): NANNETTE C MOORER LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 VARDEN DR
AIKEN SC
29803-5285
US

IV. Provider business mailing address

33 VARDEN DR
AIKEN SC
29803-5285
US

V. Phone/Fax

Practice location:
  • Phone: 803-642-3801
  • Fax: 803-642-5538
Mailing address:
  • Phone: 803-642-3801
  • Fax: 803-642-5538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number003089
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: