MEDICARE: MRS. TARA THOMPSON MOORE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN164184	GA

General Provider Information

NPI Number	:	1063714046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TARA THOMPSON MOORE

Provider Business Mailing Address
First Line	:	426 GA HIGHWAY 26 E
Second Line	:
City	:	COCHRAN
State	:	GA
Zip	:	31014-2837
Country	:	US
Telephone Number	:	478-934-2874
Fax Number	:	478-934-2876

Provider Business Practice Location Address
First Line	:	426 GA HIGHWAY 26 E
Second Line	:
City	:	COCHRAN
State	:	GA
Zip	:	31014-2837
Country	:	US
Telephone Number	:	478-934-2874
Fax Number	:	478-934-2876

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/24/2010
Last Update Date	:	11/24/2010

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Directions to “ MRS. TARA THOMPSON MOORE ” Practice Location

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