MEDICARE: MR. RODNEY WAYNE MOORE RN BSN CPAN CAPA

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	163WP2201X	Ambulatory Care Registered Nurse	082489	MO
2	163WP2201X	Ambulatory Care Registered Nurse	RN084407	GA
3	163WP2201X	Ambulatory Care Registered Nurse	RN9272235	FL

General Provider Information

NPI Number	:	1548593536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RODNEY WAYNE MOORE RN BSN CPAN CAPA

Provider Business Mailing Address
First Line	:	1078 FONTAINE PL.
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63137
Country	:	US
Telephone Number	:	404-918-0461
Fax Number	:	314-868-6605

Provider Business Practice Location Address
First Line	:	1078 FONTAINE PL
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63137-1705
Country	:	US
Telephone Number	:	404-918-0461
Fax Number	:	314-868-6605

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

Provider Enumeration Date	:	09/09/2009
Last Update Date	:	09/09/2009

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