MEDICARE: WANACCA EVONY 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	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1730974494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANACCA EVONY MOORE

Provider Business Mailing Address
First Line	:	7147 THOREAU CIR
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-7926
Country	:	US
Telephone Number	:	404-886-5940
Fax Number	:

Provider Business Practice Location Address
First Line	:	7147 THOREAU CIR
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-7926
Country	:	US
Telephone Number	:	404-886-5340
Fax Number	:

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

Provider Enumeration Date	:	04/14/2025
Last Update Date	:	04/14/2025

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