Healthcare Provider Details

I. General information

NPI: 1518827567
Provider Name (Legal Business Name): BUFFY RENEA MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2025
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 RED MULBERRY WAY APT 4
CHARLESTON WV
25306-6385
US

IV. Provider business mailing address

125 RED MULBERRY WAY APT 4
CHARLESTON WV
25306-6385
US

V. Phone/Fax

Practice location:
  • Phone: 304-206-5791
  • Fax:
Mailing address:
  • Phone: 304-206-5791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number69558
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: