MEDICARE: MRS. CHERMAL RONDELL MOORE NURSE PRACTITIONER

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	363L00000X	Nurse Practitioner	902980	MS

General Provider Information

NPI Number	:	1649745241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHERMAL RONDELL MOORE NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	2240 TALLABOGUE RD
Second Line	:
City	:	FOREST
State	:	MS
Zip	:	39074-8592
Country	:	US
Telephone Number	:	601-826-5561
Fax Number	:

Provider Business Practice Location Address
First Line	:	1017 W BEACON ST
Second Line	:
City	:	PHILADELPHIA
State	:	MS
Zip	:	39350-3218
Country	:	US
Telephone Number	:	769-200-0730
Fax Number	:

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

Provider Enumeration Date	:	10/10/2018
Last Update Date	:	10/10/2018

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