{
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"EIN": null,
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"LastName": "MOORE",
"FirstName": "STEPHANIE",
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"NamePrefix": null,
"NameSuffix": null,
"Credential": "L.M.P.",
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "1615 COBB PKWY N APT 6204",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MARIETTA",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30062-9205",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "206-930-4200",
"MailingAddressFaxNumber": "206-760-0266",
"FirstLinePracticeLocationAddress": "5150 STILESBORO RD NW STE 430",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "KENNESAW",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "30152-7759",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "470-746-4690",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "05/02/2007",
"LastUpdateDate": "10/21/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
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"AuthorizedOfficialTitle": null,
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "174400000X",
"TaxonomyName": "Specialist",
"LicenseNumber": "010605",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}