MEDICARE: FANTASIA 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	342000000X	Transportation Network Company	29101352	TX

General Provider Information

NPI Number	:	1558218107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FANTASIA MOORE

Provider Business Mailing Address
First Line	:	2609 CARRINGTON LN
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-4005
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2609 CARRINGTON LN
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-4005
Country	:	US
Telephone Number	:	469-264-1626
Fax Number	:

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

Provider Enumeration Date	:	03/12/2026
Last Update Date	:	03/12/2026

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Directions to “ FANTASIA MOORE ” Practice Location

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