MEDICARE: JODIAN DAINER MOORE RN

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	163W00000X	Registered Nurse	152451	CT

General Provider Information

NPI Number	:	1629892625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODIAN DAINER MOORE RN

Provider Business Mailing Address
First Line	:	192 NORFOLK ST
Second Line	:
City	:	WEST HAVEN
State	:	CT
Zip	:	06516-2559
Country	:	US
Telephone Number	:	203-909-8400
Fax Number	:

Provider Business Practice Location Address
First Line	:	192 NORFOLK ST
Second Line	:
City	:	WEST HAVEN
State	:	CT
Zip	:	06516-2559
Country	:	US
Telephone Number	:	203-909-8400
Fax Number	:

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

Provider Enumeration Date	:	11/14/2024
Last Update Date	:	11/14/2024

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