Healthcare Provider Details

I. General information

NPI: 1639073885
Provider Name (Legal Business Name): BRIANNA MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7247 DARK MOON
CONVERSE TX
78109-3698
US

IV. Provider business mailing address

7247 DARK MOON
CONVERSE TX
78109-3698
US

V. Phone/Fax

Practice location:
  • Phone: 210-721-9961
  • Fax:
Mailing address:
  • Phone: 210-721-9961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number1090611
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: